Extraordinary approaches for treatment of complex tibial and popliteal arterial occlusions

Abstract

Objective The purpose of this study is to evaluate the efficacy and safety of different tibiopedal approaches as alternative methods for failed antegrade recanalization of popliteal and infrapopliteal arterial occlusions. Patients and methods A prospective study was done at Vascular Surgery Department, Zagazig University Hospitals, from February 2015 to June 2018. During this period, 73 patients with critical lower limb ischemia with popliteal and/or infrapopliteal lesions underwent endovascular intervention. Antegrade recanalization failed in 17 patients (nine males and eight females with the mean age 68.6±9.8 years). Retrograde tibiopedal approach was tried in them. Six patients were Rutherford category 4 (complaining of rest pain), eight patients were Rutherford category 5 (had ischemic ulcers), and three patients were Rutherford category 6 (had gangrene). The mean ankle brachial index was 0.39±0.11. Three patients had occlusions in the popliteal artery only, 11 patients had tibial occlusions, and three patients had combined popliteal and tibial occlusions. The mean length of lesions was 9.7±2.8\u2009cm. Eleven (64.8%) patients had Trans-Atlantic Inter-Society Consensus II C lesions and six (35.2%) patients had Trans-Atlantic Inter-Society Consensus II D lesions. Results We succeeded in 13 (76.5%) patients to cross the occlusion and recanalyze the target vessel [completing the procedure from the antegrade approach in eight (47.1%) patients, and completing the procedure from the retrograde approach in five (29.4%) patients]. The mean ankle brachial index was improved significantly from 0.39±0.11 before to 0.78±0.12 after the intervention (P<0.01). Conclusion Retrograde tibiopedal approach can be used safely as a bailout to increase the technical success rate and limb salvage for failed antegrade recanalization of popliteal and infrapopliteal arterial occlusions.