Retrograde ankle tibial artery approach for endovascular treatment of below-knee chronic critical limb ischemia: appraisal of early outcome and complications

Background
Infragenicular arterial total occlusion is a major cause of critical ischemia of the lower limbs (CLTI) treated by endovascular intervention. Retrograde pedal artery access is an alternative method to cross total occlusion from below when antegrade passage fails. The aim of this study was to evaluate the short-term outcome in terms of patency, limb salvage, redoangioplasty rate, and complications.
Patients and methods
From June 2018 to July 2019, adult patients who had critical lower limb ischemia (Rutherford 4 and 5) were admitted to the vascular surgery unit of Alexandria main university hospital and department of CLTI clinical and experimental surgery at Alexandria medical research institute. They all were planned to be treated by infragenicular angioplasty. After failure of antegrade lesion crossing, angioplasty was done via retrograde access. Patients were followed for outcome and complications for 6 months.
Results
A total of 20 patients were included, comprising 14 (70%) males and six (30%) females. Mean age±SD was 71±13.5 years. Overall, 85% were diabetic, 75% hypertensive, 30% coronary heart disease, and 80% were smokers. CLTI clinical presentation was ischemic rest pain (20%) and tissue loss and gangrene (80%). Technical success was 85%. There were no procedural mortalities or complications except one case of limited leg hematoma (5%). The 6-month mortality was 5.8%, and major amputation was 5.8%. The 6-month primary and secondary patency rates were 62.5 and 87.5%, respectively, whereas the 6-month limb salvage rate was 93.75%.
Conclusions
Retrograde pedal access angioplasty to treat below-knee CLTI is a safe and feasible alternative to antegrade tibial angioplasty when it fails, with similar limb salvage and acceptable complications, but with possible higher reintervention rate, which needs to be studied further on a larger scale.