Open Proximal Endarterectomy with Retrograde Access and Stenting: A Novel Technique for Lower Extremity
David N Blitzer1,2, Nicholas P Rolle2, Hossam Abdou2
1Division of Vascular Surgery, Department of Surgery, 1479University of Maryland Medical Center, Baltimore, MD, USA.
Insights
The novel Open Proximal Exposure with Retrograde Access and Stenting (OPERAS) technique effectively treats challenging chronic limb-threatening ischemia (CLTI) with chronic total occlusions. This method demonstrates high technical success and limb salvage rates, offering a new option for complex cases.
Area of Science:
- Vascular Surgery
- Endovascular Interventions
- Ischemia Management
Background:
- Chronic limb-threatening ischemia (CLTI) presents significant clinical challenges, particularly with chronic total occlusion (CTO) lesions.
- Existing endovascular approaches for CLTI with CTOs are often difficult and have limited success rates.
- A novel technique is needed to improve outcomes for patients with complex CLTI.
Purpose of the Study:
- To describe and evaluate the efficacy of the Open Proximal Exposure with Retrograde Access and Stenting (OPERAS) technique.
- To assess OPERAS as a solution for challenging CTO lesions in CLTI.
- To determine the technical success, complication rates, and limb salvage associated with OPERAS.
Main Methods:
- A retrospective case series was conducted at a single tertiary academic center.
- The study included patients who underwent the OPERAS intervention between January 2019 and March 2020.
- Data collected included demographics, peri-operative details, and follow-up information, with analysis of length of stay, complications, re-interventions, and amputation-free survival at 1 year.
Main Results:
- Nine limbs underwent the OPERAS procedure, with common femoral artery endarterectomy for inflow.
- All cases achieved successful stenting of the superficial femoral artery (SFA), with seven also treated in the popliteal artery.
- Immediate technical failure was 0%, with no major post-operative complications. Ankle-brachial index significantly improved (P < .001), and 1-year amputation-free survival was 88.9% with 67% limb-based patency.
Conclusions:
- The OPERAS technique offers a hybrid revascularization option for severe, anatomically complex CLTI limbs (GLASS III) when autogenous conduits are unavailable.
- OPERAS improves technical success in luminal re-entry for subintimal techniques by direct visualization.
- The technique effectively addresses inflow issues concurrently with femoropopliteal disease and can be used in cases with distal tissue loss.
Background:
Treatment of chronic limb threatening ischemia (CLTI) poses a significant clinical challenge despite recent medical advancements. Chronic total occlusion (CTO) lesions make endovascular approaches to CLTI particularly challenging. Open proximal exposure with retrograde access and stenting (OPERAS) aims to solve this challenge through retrograde subintimal crossing of a CTO with direct visualization of proximal re-entry into the true lumen. We describe this novel technique and present its efficacy in eight patients.
Methods:
We conducted a retrospective case series at a single tertiary academic center. Data for patients who received OPERAS intervention included demographics, peri-operative details, and follow-up information. Statistical analysis was performed on length of stay, major post-operative complications, further intervention, clinical progression at 1 year, and amputation-free survival at 1 year. Immediate technical failure (ITF) and limb-based patency (LBP) at 1 year were calculated.
Results:
Nine limbs underwent OPERAS between January 2019 and March 2020. Inflow was achieved with common femoral artery endarterectomy. All limbs underwent balloon angioplasty and stenting of the SFA, and seven underwent the same procedure in the popliteal artery. ITF was 0% for all nine cases. There were no major post-operative complications, and ankle-brachial index significantly improved pre-and post-operatively (P < .001). Eight limbs (88.9%) sustained amputation-free survival at 1 year, and overall LBP was 67% at 1 year.
Conclusion:
Our study presents a hybrid revascularization option to address severe, anatomically complex limbs (GLASS III) that lack a single autogenous conduit for open surgical revascularization. OPERAS addresses a main point of technical failure of subintimal techniques by directly visualizing the wire in the true lumen. Our data suggest that OPERAS can be effective to: (1) improve technical success of luminal re-entry following a subintimal approach; (2) address inflow concurrently with severe femoropopliteal disease; and (3) can be utilized when distal tissue loss is involved.
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