Retrospective Analysis of Major Adverse Outcomes of Retrograde Access Revascularization Patients

Lower extremity endovascular revascularizations in patients with peripheral artery disease traditionally utilize contralateral femoral artery access. However, retrograde access (RA) from a tibial and/or pedal vessel is increasingly used as an access point to facilitate crossing a lesion. This study aims to compare outcomes between traditional antegrade access (AA) and RA patients to determine if RA is associated with greater risk of negative outcomes.

This retrospective analysis included 573 endovascular atherectomies from 2 institutions from 2014 to 2022. RA patients were defined as patients who underwent endovascular access from the anterior tibial, posterior tibial, peroneal, or dorsalis pedis artery. Major adverse limb event (MALE) was defined as open arterial bypass surgery, minor amputation, or major amputation. Multivariate logistic regression models calculated the odds ratio of MALE and controlled for demographics and comorbidities. Cox proportional hazard analysis was performed to analyze time-to-event data and controlled for demographics and comorbidities.

Among the 573 endovascular revascularizations, 90 (15.7%) were RA revascularizations, 70 of which were successful crossing lesions via a retrograde approach. Patients requiring RA were more likely to have a previous history of surgical interventions (37.9% vs. 58.6%, P < 0.001) and a lower average number of preoperative patent tibial run-off vessels (1.8 vs. 1.1, P < 0.001). In this analysis, patients undergoing RA were not at greater risk of access site complications defined as hematomas, access site thrombosis, infection, or pseudoaneurysm (5.6% vs. 1.6%, P = 0.6). On multivariate logistic regression, RA patients were not at higher odds of MALE (odds ratio = 0.80, confidence interval (CI) = [0.32-1.94], P = 0.6). Cox proportional hazard analysis showed that RA patients did not have a greater hazard ratio for MALE (hazard ratio = 0.72, CI = [0.35-1.49], P = 0.4).

Despite worse preoperative conditions, RA patients were not at greater risk of MALE or access site complications than AA patients. The lack of difference in longitudinal outcomes, albeit with a smaller RA cohort, indicates that RA may be as safe and effective as AA for patients whose occlusions cannot be crossed from the antegrade direction.