Distal Puncture-Assisted Bidirectional Endovascular Therapy for Femoropopliteal Chronic Total Occlusion: Efficacy and
Yuichiro Hosoi1, Yuki Katagiri1, Shuko Iwata2
1Department of Cardiovascular Medicine, Sapporo Higashi Tokushukai Hospital, Japan.
Insights
Distal puncture-assisted bidirectional endovascular therapy (EVT) shows high success for femoropopliteal chronic total occlusions (FP-CTO). This approach demonstrated good limb salvage and survival rates with no major access-site complications, though further research is needed.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Femoropopliteal chronic total occlusions (FP-CTO) present significant treatment challenges.
- Conventional endovascular therapy (EVT) may face difficulties in crossing these lesions.
- Novel access strategies are needed to improve EVT outcomes for complex FP-CTO.
Purpose of the Study:
- To evaluate the efficacy of distal puncture-assisted bidirectional EVT for de novo FP-CTO.
- To assess the periprocedural safety and complication profile of this technique.
- To determine long-term outcomes including limb salvage and survival.
Main Methods:
- A multicenter retrospective study involving 5 institutions (2019-2022).
- Analysis of 94 procedures for outcomes and complications (CIRSE grade ≥3 for major complications).
- Assessment of 87 patients for major amputation and mortality based on the index procedure.
Main Results:
- High wire-crossing success (98.9%) and technical success (84.0%) were achieved.
- Overall complication rate was 23.4%, with 8.5% major complications.
- No major distal access-site complications were observed; distal embolization occurred in 6.4% (CIRSE grade 1).
- One-year outcomes included 82.0% freedom from target lesion revascularization, 97.0% limb salvage, and 85.6% overall survival.
Conclusions:
- Distal puncture-assisted bidirectional EVT is effective for complex FP-CTO, offering high success rates.
- The technique demonstrated a favorable safety profile regarding access-site complications.
- While promising, findings require cautious interpretation due to uncaptured failed attempts and unclear distal embolization attribution.
Purpose:
To evaluate the efficacy and periprocedural safety of distal puncture-assisted bidirectional endovascular therapy (EVT) for de novo femoropopliteal chronic total occlusion (FP-CTO).
Methods:
This multicenter retrospective study included 5 institutions and was conducted between 2019 and 2022. Outcomes and complications were analyzed per procedure (94 procedures); major amputation and mortality were assessed per patient based on the index procedure (87 patients). Major complications were defined as the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification grade ≥3.
Results:
Wire-crossing success was 98.9%, and technical success was 84.0%. Complications occurred in 23.4% of procedures, including major complications in 8.5% and distal access-site complications in 10.6%, with no major distal access-site complications observed. Distal embolization occurred in 6.4% of procedures and was uniformly graded as CIRSE grade 1. At 1 year, freedom from target lesion revascularization was 82.0%, whereas limb salvage and overall survival were 97.0% and 85.6%, respectively.
Conclusion:
In this selected multicenter cohort, distal puncture-assisted bidirectional EVT achieved a high wire-crossing success rate, with no adjudicated major distal access-site complication identified using the CIRSE classification. However, these safety findings should be interpreted with caution, as failed distal puncture attempts were not captured and the temporal attribution of distal embolization could not be fully established.Clinical ImpactDistal puncture-assisted bidirectional endovascular therapy may be a useful bailout or planned strategy for complex femoropopliteal chronic total occlusions when conventional antegrade crossing is difficult. This multicenter study provides contemporary procedural outcomes and Cardiovascular and Interventional Radiological Society of Europe-graded complication profiles, allowing clinicians to interpret not only technical success but also the severity and clinical relevance of complications. The findings may help operators discuss procedural risk, select appropriate access strategies, and standardize complication reporting in femoropopliteal CTO interventions. Further studies including attempted but unsuccessful distal puncture cases are needed to define the overall risk-benefit profile of this approach.
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