Retrograde Access Bailout Versus Bypass Surgery for Failed Antegrade Infrainguinal Angioplasty
M Elkassaby1, M Mabrouk2, Y M Alkhateeb3
1Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland; Department of Vascular Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
Insights
Retrograde angioplasty is a successful bailout for failed antegrade procedures in chronic limb-threatening ischemia (CLTI) patients. This approach offers comparable limb salvage to bypass surgery but with fewer amputations and lower mortality.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Interventions
Background:
- Peripheral arterial disease (PAD) and chronic limb-threatening ischemia (CLTI) present significant clinical and economic challenges.
- Antegrade angioplasty is a primary treatment for infra-inguinal disease, but failure necessitates alternative strategies.
- Evaluating bailout options after failed antegrade angioplasty is crucial for limb salvage.
Purpose of the Study:
- To compare the efficacy of retrograde angioplasty as a bailout strategy versus bypass surgery and conservative management.
- To assess limb salvage rates, amputation rates, and survival outcomes in patients with failed antegrade angioplasty for CLTI.
- To determine the safety and effectiveness of retrograde access in complex infra-inguinal occlusive disease.
Main Methods:
- Retrospective multi-center study of 1052 infra-inguinal angioplasty procedures (Jan 2021-Jan 2023).
- Included patients with CLTI (Rutherford classes 4-6) and failed antegrade angioplasty.
- Compared outcomes for retrograde angioplasty (n=38), bypass surgery (n=58), and conservative management (n=33).
Main Results:
- Retrograde angioplasty achieved a 90% success rate, comparable to bypass surgery (91%).
- Major amputation rates were significantly lower with retrograde angioplasty (39.5%) compared to bypass (50%) and conservative management (87.8%, p=0.027).
- Amputation-free survival was significantly higher, and mortality was lowest in the retrograde group over 3-year follow-up (p=0.001).
Conclusions:
- Retrograde angioplasty is a safe and effective alternative to bypass surgery after failed antegrade procedures in CLTI.
- It demonstrates comparable limb salvage and reduced perioperative risks.
- Conservative management showed limited efficacy with higher amputation and mortality rates.
Background:
Peripheral arterial disease and chronic limb-threatening ischemia (CLTI) pose significant health and economic burdens. Antegrade angioplasty is a common revascularization technique for infrainguinal disease, but complex cases may necessitate alternative interventions after failure. This study evaluates the efficacy of retrograde access as a bailout strategy compared to bypass surgery and conservative management in patients with failed antegrade angioplasty.
Methods:
This retrospective multicenter study analyzed 1,052 infrainguinal angioplasty procedures conducted between January 2021 and January 2023, with follow-up data collected until June 2024. Patients with CLTI (Rutherford classes 4-6) were included. Failed antegrade cases were grouped by treatment: retrograde angioplasty, bypass surgery, or conservative management. Primary endpoints were major amputation and limb salvage, with secondary endpoints of complications and survival. Kaplan-Meier survival analysis assessed amputation-free survival.
Results:
Of 129 failed antegrade angioplasty cases, 38 were managed with retrograde angioplasty, 58 with bypass surgery, and 33 conservatively. Retrograde access was more frequently performed on the same admission (82%), showing a success rate of 90%, comparable to bypass surgery at 91%. Major amputation rates were lowest in the retrograde group (39.5%) versus bypass (50%) and conservative groups (87.8%, P = 0.027). Amputation-free survival was significantly higher in the retrograde group, with the lowest mortality rate over the 3-year follow-up (P = 0.001).
Conclusion:
Retrograde angioplasty offers a safe, effective alternative to bypass surgery following failed antegrade procedures in CLTI patients, demonstrating comparable limb salvage outcomes and reduced perioperative risks. Conservative management led to higher amputation rates and mortality, indicating limited efficacy. These findings underscore retrograde access as a valuable approach for limb salvage in complex infrainguinal occlusions.
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