Figura 1. A. and B. Angiography reveals the occlusion of the superficial femoral artery from the ost...

Figura 2. A. Scarce blood supply at foot dorsal level where the patent posterior tibial artery can b...

Figura 3. A. and B. Balloon angioplasty of SFA and popliteal artery. C. and D. Positioning and impl...

Figura 4. A-C. Angiography after treatment showing patency from the ostium until the distal third of...

Introduction

Lower limb critical ischemia is a serious manifestation of lower limb peripheral arterial disease. It poses a high risk of amputation or complications associated with tissue loss, gangrene, sepsis or multiple organ failure.1 This ischemia is characterized by the coexistence of pain at rest or foot or toes ulceration or gangrene. It often presents as a chronic total coronary occlusion (CTO) in the femoropopliteal segment (FP).2

Endovascular treatment is the therapy of choice to revascularize patients with critical limb ischemia thanks to its results and low morbidity and mortality rates reported.3 Technical success is defined as the arrival of direct flow towards the foot through, at least, 1 patent infrapopliteal blood vessel.

Access via femoral approach—antegrade—is the common access route to perform an angioplasty of lower limb arteries. The rate of technical failure regarding revascularization is somewhere between 10% and 40%. Retrograde approach techniques via the accesses opened in anterior and posterior tibial, feet, fibular, and metatarsal arteries respond to the goal of reducing the rate of technical failure.

Case report

This is the case of a 92-year-old woman with a positive cardiovascular risk factor for arterial hypertension. Her past medical history included non-anticoagulated atrial fibrillation, and peripheral arteriopathy with intermittent claudication at 54 yards. Also, the patient’s medical history included hip fracture with metal prosthesis in right lower limb. She is referred from a different center with lower limb critical ischemia of 20-day evolution with necrotic ulcer of right hallux up to the third ipsilateral phalange (Rutherford V).4

The physical examination confirmed the presence of palpable femoral pulse grade 2/2 with reduced popliteal pulse and absence of anterior tibial artery with slightly reduced temperature, paleness, delayed capillary pulse, and right foot hyperalgesia. The ankle-brachial index (ABI) before treatment was 0.5.

Other additional tests:

- Laboratory tests: RBC, 39%: WBC, 9.7 million/mm3; platelets, 200 million/mm3 creatinine levels, 1.4 mg/dL; urea levels, 57 mg/dL.

- Arterial Doppler ultrasound: occlusion of right superficial femoral artery.

Procedure is performed under sedoanalgesia and systemic heparinization through antegrade puncture and insertion of a 6-Fr introducer sheath (Avanti Plus; Cordis Corporation, Miami Likes, FL, United States) into the right common femoral artery. The diagnostic arteriography performed reveals a total chronic coronary occlusion at superficial femoral artery (SFA) level from the ostium towards the distal third with recanalization at popliteal level due to collateral circulation (Figures 1 A-B). An occlusion of the anterior tibial artery is revealed at infrapopliteal level with distal recanalization. Afterwards, a 5-Fr diagnostic catheter (ImpulseTM MPA2, Boston Scientific, MA, United States) is mounted on a 150 cm 0.035 in J-tip hydrophilic guidewire (RadiofocusTM Guide Wire M, Terumo Corporation, Tokyo, Japan) that is advanced towards the mid third of the SFA. Then, it is exchanged for a 4-Fr hydrophilic vertebral catheter (RadiofocusTM GlidecathTM, Terumo Corporation, Tokyo, Japan) in an attempt to recanalize the crossing. Procedure is difficult due to the presence of severe calcification with failing antegrade revascularization (Figure 1C).

The posterior tibial artery is treated with retrograde puncture at distal third level with a 21G needle (Cook Medical Inc. Bloomington, IN, United States) with fluoroscopy guidance. Afterwards, a 5-Fr radial introducer sheath is inserted (Terumo Corporation, Tokyo, Japan) followed by a 0.014 in guidewire (Cross-IT 300 XT, Abbott Vascular, Santa Clara, CA, United States) mounted over a 2.0 mm x 20 mm OTW balloon (Ryujin Plus, Terumo Corporation, Tokyo, Japan) until reaching the inside of the vertebral catheter placed via antegrade access at the SFA mid third level to eventually connect the retrograde and antegrade accesses (SAFARI technique)5 (Figures 2 A-C). Afterwards, access is reversed and angioplasty is completed with a 3 mm x 80 mm balloon (RapidCross, Medtronic, Minneapolis, MN, United States), a 5 mm x 120 mm OTW balloon (Admiral Xtreme, Medtronic, Minneapolis, MN, United States) (Figures 3 A-B), and implantation of three 6 mm x 120 mm self-expanding stents (EverflexTM, Medtronic, Minneapolis, MN, United States) covering the ostium until the distal third of the right SFA (Figures 3 C-D).

Control angiography shows patency in the entire territory of the right superficial femoral artery, and in the popliteal and right posterior tibial arteries with increased infrapatellar flow. These arteries had been hypoperfused before the procedure (Figures 4 A-F). Homeostasis was performed with compressive bandage at the posterior tibial puncture site without further complications.

Technical success facilitated the revascularization of the previously occluded superficial femoral artery that had caused the problem, and increased flow while keeping patent, at least, 1 infrapopliteal vessel. In the immediate postoperative period, the foot artery recovered pulse with an ABI (angle-brachial index) of 1 with better color, capillary refill, and with normal temperature.

At the outpatient follow-up, a control Doppler echocardiography was performed at 6 months with preserved right posterior femoral and tibial flow that progressed into the healing of the lesion and no pain at rest while on ASA, clopidogrel, cilostazol, and statins.

DISCUSSION

The presence of critical ischemia (pain at rest or trophic lesions) requires early revascularization treatment due to the high risk of losing the limb in an elevated number of patients causing functional disability, and social and economic losses. The rate or primary amputation at 1 year is 25%.1

Over the last decade, the arrival and perfectioning of new percutaneous technologies has turned into a significant growth of endovascular strategies.6 However, in complex cases of extensive occlusions, the rate of failure is somewhere between 10% and 40% when performed via antegrade femoral access. Even in reference centers, the rate of technical failure associated with long chronic total coronary occlusions can be up to 17.8%.7 When this happens, an option that should be taken into consideration is retrograde access8 that is associated with higher chances of technical success (of up to 85%) in cases with failing conventional antegrade access.9 This approach should be performed with extreme caution and, on many occasions, it is the only patent infrapatellar vessel responsible for keeping the limb viable.

Good angiographic results were reported when proper flow was reestablished in the ulcer region, which facilitated the healing of the lesion, and prevented amputations.

CONCLUSION

Peripheral angioplasty via retrograde access in long occlusive lesions is a viable therapeutic option.This new therapeutic strategy allows the endovascular revascularization of most patients with successful results, which improves the viability of the limb with lower rates of amputation, morbidity, and mortality associated with this condition.

1. Guering E. Isquemia crítica de miembros inferiores. Sociedad latinoamericana de Cardiología Intervencionista 2012;81:3-7.

2. Duque-Goicochea J, Lara González VR, García-Lugo JI, et al. Técnica PRESTO para la revascularización endovascular del segmento femoropoplíteo. Rev Mex Angiol 2021;49(1):33-40.

3. Conrad MF, Crawford RS, Hackney LA, et al. Endovascular management of patients with crítical limb ischemia. J Vasc Surg 2011;53(4):1020-5.

4. Rutherford RB. Clinical staging of acute limb ischemia as the basis for choice of revascularization method: when and how to intervene. Semin Vasc Surg 2009;22:5-9.

5. Spinosa DJ, Harthun NL, Bissonette EA, et al. Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interv Radiol 2005;16(1):37-44.

6. Jozami S, Albertal M, Zaefferer P, et. al. Tratamiento de la isquemia crítica de miembros inferiores. Rev Argent Cardiol 2010;78:129-33.

7. Rabellino M, Peralta O, Mónaco RG. Soluciones simples a problemas complejos en la revascularización endovascular de los miembros inferiores: accesos retrógrados infrapatelares. Rev Hosp Ital B. Aires 2013;33(3):101-5.

8. Patrone L, Stehno O. Retrograde insertion of the outback reentry device from a tibial artery for complex infrainguinal recanalization CVIR. Endovascular 2019;30;2(1):47.

9. Dini A, Mauro D, Tamashiro A, et al. Consenso de Revascularización de Miembros Inferiores del Colegio Argentino de Cardioangiólogos Intervenciones. Revista Argentina de Cardioangiología Intervencionista 2018;9(3):136-161. Doi: 10.30567/RACI/20183/0136-0161.

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Critical limb ischemia: case presentation of retrograde endovascular approach

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