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Published on: September 22, 2020
Combined antegrade-retrograde intervention to improve chronic total occlusion recanalization in high-risk critical
Sridhar Venkatachalam1, Mathew Bunte1, Peter Monteleone1
1Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
Insights
For critical limb ischemia (CLI) patients unsuitable for surgery, a combined antegrade-retrograde approach significantly improves chronic total occlusion (CTO) crossing success. This safe and effective strategy enhances endovascular treatment outcomes for limb salvage.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Chronic total occlusions (CTOs) in critical limb ischemia (CLI) pose challenges when conventional antegrade approaches fail.
- Surgical revascularization is often not an option for these high-risk patients, leading to poor limb outcomes.
Purpose of the Study:
- To evaluate the efficacy of a combined antegrade-retrograde endovascular approach for CTO lesions in CLI patients.
- To determine if this combined strategy improves recanalization success compared to antegrade-only attempts.
Main Methods:
- Infrainguinal endovascular interventions were attempted using an antegrade approach in 27 CLI patients.
- In 11 limbs where the antegrade approach failed, a combined antegrade-retrograde approach with distal retrograde access was employed.
- Primary endpoint was successful CTO lesion crossing; secondary endpoints included technical success, amputation, wound healing, and target lesion revascularization (TLR).
Main Results:
- The combined approach achieved successful CTO lesion crossing in 82% of attempted limbs.
- Overall CTO crossing success improved from 61% with antegrade alone to 93% with the combined approach.
- Technical success improved from 50% to 79%, with a 9% major amputation rate and 18% TLR rate during a median 4-month follow-up. No major procedural complications occurred.
Conclusions:
- The combined antegrade-retrograde approach is a safe and effective strategy for endovascular therapy in CLI patients.
- This approach significantly improves recanalization success and technical outcomes in patients unsuitable for surgery.
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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