Combined antegrade-retrograde intervention to improve chronic total occlusion recanalization in high-risk critical limb ischemia

Sridhar VenkatachalamMathew BuntePeter MonteleoneAaron LincoffMichael MaierMehdi H Shishehbor

Background: When conventional antegrade attempts (antegrade approach) to cross chronic total occlusion (CTO) lesions in critical limb ischemia (CLI) fail, and if surgical revascularization is not possible, limb outcomes may be expected to be poor. In this high-risk cohort, we sought to examine whether combined antegrade-retrograde intervention with the simultaneous use of a distal retrograde access (combined approach) improves recanalization success.

Methods: From September 2011 to 2012, infrainguinal endovascular interventions were first attempted using antegrade approach in 27 consecutive patients (28 limbs) with CLI and infrainguinal CTO. All patients were poor surgical candidates. In the 11 limbs where antegrade approach failed, the combined approach was attempted. The primary end point was successful CTO lesion crossing. The secondary end points were technical success with ≤30% diameter residual stenosis of the target lesion, major amputation (transtibial or above), wound healing, target lesion revascularization (TLR), and access site complications that include hematoma requiring exploration or transfusion, arteriovenous fistula, or pseudoaneurysm.

Results: Of the 11 limbs that underwent combined approach, the primary end point was achieved in 9 limbs (82%). More notably, among the 28 limbs overall, CTO lesion crossing improved from 61% (95% confidence interval [CI]: 0.41-0.78) using antegrade approach alone to 93% (95% CI: 0.75-0.99) when supplemented by the combined approach. Similarly, the secondary end point of technical success improved from 50% (95% CI: 0.31-0.69) to 79% (95% CI: 0.59-0.91), respectively. Major amputation, wound healing (inclusive of postamputation status), and TLR rates were 9%, 100%, and 18%, respectively, during a median follow-up of approximately 4 months. No major procedural complications occurred with the combined approach.

Conclusion: Among CLI patients who are poor surgical candidates, the combined approach is a viable, safe, and effective strategy to improve overall success with endovascular therapies.

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