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Ultrasound-guided retrograde tibial access through chronically occluded tibial arteries: a last resort recanalization
Murat Serhat Aygun1, Derya Tureli2, Sinan Deniz3
1Department of Radiology, Koç University, İstanbul, Turkey.
Insights
Ultrasound-guided retrograde tibial access is a feasible bailout technique for critical limb ischemia (CLI) patients with chronically occluded arteries. This method successfully recanalized nearly half of previously untreatable tibial arteries.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Medical Imaging
Background:
- Critical limb ischemia (CLI) poses a significant challenge, often involving complex tibial artery occlusions.
- Conventional antegrade tibiopedal recanalization techniques may fail in cases of chronic total occlusions.
- Alternative strategies are crucial for limb salvage in CLI patients with no-option arteries.
Purpose of the Study:
- To assess the feasibility of ultrasound (US)-guided retrograde tibial access.
- To evaluate this technique as a bailout procedure for CLI patients with chronically occluded tibial arteries.
- To determine the efficacy of retrograde access in achieving endovascular recanalization after failed antegrade attempts.
Main Methods:
- Retrospective analysis of 51 CLI patients undergoing US-guided retrograde tibial access.
- Target arteries were chronically occluded distally.
- Real-time US guidance was employed, with fluoroscopy used adjunctively for guidewire advancement.
Main Results:
- Successful guidewire placement in the occluded artery lumen was achieved in 81% of patients.
- Overall treatment success, defined by in-line flow, was 49%.
- No significant procedure-related complications were observed; limb salvage rates were comparable to other studies.
Conclusions:
- Ultrasound-guided retrograde tibial access is technically challenging but feasible for treating chronically occluded tibial arteries in CLI.
- This bailout strategy can convert previously untreatable occlusions into successful recanalizations.
- The technique offers a potential solution for limb salvage in complex CLI cases.
Abstract:
PURPOSE We aimed to demonstrate the feasibility of ultrasound (US)-guided retrograde tibial access through chronically occluded tibial arteries as a bailout endovascular recanalization procedure in patients with critical limb ischemia (CLI). METHODS Fifty-one CLI patients with failed conventional antegrade tibiopedal recanalization required retrograde tibiopedal access in the same session. In all of these patients, the target tibial artery was chronically occluded in at least the distal half of the cruris. Access attempts were made under real-time US by a single operator experienced in image-guided vascular access procedures. Fluoroscopy was used only as an adjunct during advancement of a 0.018 inch guidewire. If access to the artery was successful by the retrograde route, the occluded artery was usually predilated with a 2 mm balloon, and the standard endovascular treatment was mostly performed through the antegrade route. RESULTS Patients had athereosclerosis (n=35) or Buerger's disease (n=32) and presented with Rutherford category IV and category V. Successful placement of a guidewire in the occluded artery lumen was achieved in 81% of all patients, whereas, treatment success, i.e. angiographic demonstration of in-line flow at the end of procedure, was achieved in 49%. No significant procedure-related complications were observed. Of 33 limbs with initially successful endovascular treatment, 6 required minor and 1 required major amputation during follow-up. CONCLUSION US-guided retrograde access through completely occluded tibial arteries is difficult but feasible. Half of the tibial arteries that could not be recanalized otherwise were converted to successful recanalization by this method.
