Success of Retrograde Tibial Artery Approach in Lower Extremity Revascularization
Objectives: To evaluate the safety and efficacy of retrograde tibial approach in revascularization of lower extremity for treating ischemia in anatomically challenging patients. To identify the patency of access tibial vessels in follow-up. Methods: In this IRB approved retrospective study 56 patients underwent 60 procedures between 2012 to 2016, treating 112 vessels using retrograde approach due to flush occlusion, inability to cross lesion in antegrade fashion, failed bypass or hostile groin. All but 2 procedures were performed between 2014 and 2016. Demographic data, Rutherford classes, vessels treated, and the vessel approach were tabulated. Success of the procedure, type of procedure, complications, amputations, deaths, and patency of access tibial vessel and treated vessel were recorded. Technical success was defined as residual stenosis of <50%. Restenosis was categorized as two times increase in velocity at the site of previous treatment. Reintervention was performed when the patient became symptomatic and had restenosis of >50%. In follow up, access and treatment area patency were evaluated by both physical exam and ultrasound. Life table analysis was performed and Kaplan Meier curve was created. Results: There were 56 patients (34 males), average age 67 ± 11.3 years. Rutherford categories: class II (n=1), class III (n=39), class IV (n=5), class V (n=13), and class VI (n=2). Risk factors included diabetes (n=25), hypertension (n=45), smoking (n=46), and decreased renal function (n=25). Lesion crossing was successful in 59/60 limbs. In one patient, procedure was halted due to local dissection. Within 30 days of procedure, both Rutherford 6 patients (2/2) required major amputations, as well as one of 13 class 5 patients. There was no 30 day mortality. In 112 lesions treated, technical success rate was 105/112 (93.8%). In follow up, 63/112 (56.3%) vessels remained patent at 19 months (mean follow up 5. 6 ± 5.2 months) without any further interventions. 16/112 vessels required reintervention with median patency of 6 months and 100% occlusion at 10 months (mean follow up 5. 7 ± 4. 8 months). In follow up, 32/37 (86.5%) of the AT, 19/21 (90.5%) of PT, and 2/2 (100%) of peroneal access groups remained patent. Occlusion caused no adverse outcome. Conclusions: In this anatomically challenging patient group, tibial approach can be safely utilized with good medium term results. Retrograde approach rarely causes access vessel occlusion and results in no adverse outcome. Access vessel is not compromised for a future bypass. In Rutherford class VI patients, retrograde approach may not be advisable.