Retrograde Femoral Access Flipped Antegrade Technique and its Effect on Patient Outcomes Following Lower Extremity...

Common femoral artery access is a critical step in the endovascular treatment of peripheral artery disease. Traditionally, access is obtained either by a retrograde approach from the contralateral leg with an "up-and-over" aortic bifurcation technique, or in an antegrade fashion in the ipsilateral leg. Retrograde arterial access flipped antegrade in the ipsilateral femoral artery incorporates the technical ease of retrograde access (RA) with mechanical advantages of antegrade access (AA). There are limited studies directly comparing these techniques. The objective of this study is to describe and compare the different techniques for accessing the common femoral artery for diagnostic and therapeutic endovascular infrainguinal interventions.

This is a retrospective cohort study of patients undergoing lower extremity diagnostic and therapeutic angiography through either contralateral retrograde (RA), ipsilateral antegrade (AA), or retrograde femoral access flipped antegrade (RAFA) between October 1st, 2018, and September 30th, 2020. Outcomes measured were technical success, complications including hematoma, hemorrhage requiring transfusion, pseudoaneurysm, and repeat operative intervention. Differences in patient and treatment characteristics were analyzed using 2-sample t-test, Fisher's exact test and Chi-squared test. Multivariable logistic regression analysis was performed to identify associations with different access techniques and study outcomes.

Of the 342 lower extremity endovascular procedures, 156 (45.6%) used RA access, 82 (24.0%) AA access, and 104 (30.4%) RAFA access. There were no significant differences in the mean age, gender, and body mass index between patients undergoing different access method cohorts (P > 0.05). The RAFA cohort had a significantly higher percentage of patients taking Plavix (46%) than retrograde (24%) and antegrade (34%) patients (P < 0.001). Patients undergoing RAFA access were less commonly active smokers (P = 0.003) or had chronic obstructive pulmonary disease (P = 0.001). Fluoroscopic confirmation of arterial puncture occurred less frequently in the AA cohort (P = 0.037). Technical success rate during therapeutic intervention was highest in the AA cohort (RA, 84%; AA, 98%; RAFA, 91%; P = 0.024). The AA cohort had the highest overall complication rate (RA, 10%; AA, 23% RAFA, 8.0%; P = 0.025) and the highest rate of requiring return to odds ratio (RA, 4.7%; AA, 17%; RAFA, 4.5%; P = 0.021). There were no significant differences in the incidence of hematoma, pseudoaneurysm, or death between all 3 cohorts (P > 0.05).

The use of a RAFA technique for infrainguinal diagnostic and therapeutic endovascular therapy is not well studied. Our study demonstrates that this technique had a high rate of technical success without increasing the risk for access site complications compared to the traditional femoral artery access.