Success of Retrograde Tibial Artery Approach in Lower Extremity Revascularization in Office-Based Setting

This study evaluated the safety and efficacy of retrograde tibial approach in revascularization of lower extremity for treating ischemia in anatomically challenging patients. In this Institutional Review Board-approved retrospective study, 56 patients underwent 60 procedures between 2012 and 2016, during which 112 vessels were treated using a retrograde approach due to flush occlusion, inability to cross lesion, failed bypass, or hostile groin. Demographic data, Rutherford classes, vessels treated, and vessel approach were noted. Type of procedure, complications, amputations, deaths, and patency of access tibial vessels and treated vessels were recorded. Technical success was defined as residual stenosis of <50%. Restenosis was defined as a two-times increase in velocity at the site of treatment. In follow-up, access and treated vessel patency were evaluated by physical examination and ultrasound imaging. Life-table analysis was performed. The χ2 test was used to test relations between risk factors and occlusion. There were 56 patients (34 males). Average age was 67 ± 11.3 years. Rutherford categories were class II (n = 1), class III (n = 39), class IV (n = 5), class V (n = 13), and class VI (n = 2). The lesion was crossed in 59 of 60 limbs. One procedure was halted due to local dissection. Within 30 days of procedure, two of two Rutherford class VI and one of 13 class V patients needed major amputation. There was no 30-day mortality. Technical success occurred in 105 of 112 vessels (93.8%). In follow-up, overall patency for 112 vessels at 19 months was 53.98%, 83 of 112 vessels (74.1%) not requiring secondary intervention had a patency of 75.4% at 19 months, and 29 of 112 vessels (25.9%) needing reintervention had a patency of 20.3% at 17 months (Fig 1). During follow-up, 32 of 37 (86.5%) of the AT, 19 of 21 (90.5%) of PT, and 2 of 2 (100%) of peroneal access vessels remained patent. Effect of various factors on vessel outcome is listed in the Table. In this anatomically challenging patient group, the tibial approach can be safely used with good medium term results. The retrograde approach rarely causes access vessel occlusion and results in no adverse outcome. Access vessel is not compromised for future bypass. Patients in Rutherford class II to III do better than those in IV to VI. Postprocedure anticoagulant treatment, excluding clopidogrel and warfarin, has a beneficial effect in improving follow-up patency.TableEffect of various factors on target vessel occlusion post interventionFactorsOR (95% CI)P valueRutherford Group (II-III vs IV-VI)2.94 (1.32-6.67).008Antiplatelet pre-op2.27 (0.92-5.59).07Antiplatelet post-op1.09 (0.44-2.68).86Warfarin pre-op0.53 (0.11-2.50).89Warfarin post-op0.35 (0.06-1.99).95Clopidogrel pre-op1.34 (0.57-3.14).50Clopidogrel post-op2.07 (0.81-5.28).12Other anticoagulants pre-op0.72 (0.17-3.04).79Other anticoagulants post-op0.14 (0.04-0.54).002aCI, Confidence interval; OR, odds ratio.aStatistically significant. Open table in a new tab