Acceso retrógrado de rescate versus cirugía de derivación para angioplastia infrainguinal anterógrada fallida

Peripheral arterial disease (PAD) and chronic limb-threatening ischemia (CLTI) pose significant health and economic burdens. Antegrade angioplasty is a common revascularization technique for infra-inguinal 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.

This retrospective multi-center study analysed 1052 infra-inguinal 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.

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).

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 infra-inguinal occlusions.