title: Retrograde Pedal Access and Endovascular Revascularization: A Safe and Effective Technique for High-Risk Patients with Complex Tibial Vessel Disease.
abstract: BACKGROUND
  Endovascular revascularization is an established approach for limb salvage in the setting of critical limb ischemia. However, failure rate of antegrade recanalization in complex femoropopliteal to infrapopliteal occlusions is as high as 20%. We report a series of 21 patients who underwent retrograde pedal access and recanalization of below-the-knee chronic total occlusions after failed antegrade attempts.
  
  
  METHODS
  This is a retrospective review of prospectively maintained data for all patients who underwent ultrasound-guided percutaneous pedal access for retrograde endovascular treatment of advanced tibial vessel disease between 2011 and 2014. All patients had undergone prior unsuccessful attempts at antegrade revascularization. Pedal vessel access was followed by angioplasty with selective stenting and completion angiogram. Patients were followed up with duplex ultrasound to evaluate for patency. Time-dependent outcomes were determined by Kaplan-Meier survival analyses. Median follow-up was 9 months.
  
  
  RESULTS
  A total of 21 patients (17 men, 4 women, mean age 68) underwent retrograde tibial recanalization. Eighty-one percent of the patients presented with Rutherford category 4, 5, or 6 critical limb ischemia. The average Prevent III amputation risk score was 7.0 ± 2.9. Eighteen patients (86%) were medium or high risk (Prevent III amputation risk score ≥ 4). Retrograde pedal access was successful in 95% of the patients (dorsalis pedis = 11, posterior tibial = 5, anterior tibial = 4). Retrograde revascularization was achieved in 14 patients (67%) using balloon angioplasty (n = 14) and additional stent placement (n = 2). Revascularization failed in 7 patients (33%). There were no pedal access site complications. Forty-eight percent of the patients experienced improvement or resolution of their symptoms. The 30-day major adverse cardiac events (MACE), major adverse limb events (MALE), and amputations were all 5%. At 1 year, limb salvage was 88 ± 8% with amputation-free survival of 61 ± 12% and freedom from MALE of 81 ± 10%. Primary assisted and secondary patencies were both 84 ± 10% at 1 year.
  
  
  CONCLUSIONS
  Early outcomes for ultrasound-guided retrograde pedal access show that it is safe, with low 30-day mortality, and a low rate of MACE. Freedom from MALE and limb salvage are both high at 1-year follow-up. This technique expands revascularization options after failed conventional endovascular antegrade approaches.
authors.affiliation: Division of Vascular Surgery, The Ohio State University, Columbus, OH. Electronic address: Hosam.ElSayed@osumc.edu.
authors.forename: Hosam
authors.initials: H
authors.lastname: El-Sayed
authors.affiliation: Methodist Cardiovascular Surgery Associates, Houston, TX.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Bennett
authors.affiliation: Methodist Cardiovascular Surgery Associates, Houston, TX.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Loh
authors.affiliation: Division of Vascular Surgery, University of Texas at San Antonio, San Antonio, TX.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Davies
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D002908:Chronic Disease; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012039:Regional Blood Flow; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013977:Tibia / Q000000981:diagnostic imaging / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D018084:Ultrasonography, Interventional; D014654:Vascular Patency