ClinicalAntegrade approach for percutaneous interventions of ostial superficial femoral artery: outcomes from a prospective series of diabetic patients presenting with critical limb ischemia☆
Introduction
Percutaneous transluminal angioplasty is the mainstay in the management of critical limb ischemia (CLI) with rates of clinical and procedural success over 80% [1], [2], [3], [4], [5], [6], [7], [8], [9]. The ipsilateral antegrade femoral access has been indicated by many authors as the first-choice approach for interventional procedures in cases of extensive atherosclerotic involvement of the infragenicular vessels [4], [5], [9]. One of the conditions strongly discouraging the choice of the antegrade ipsilateral puncture is the presence of a severe stenosis or chronic total occlusion at the origin of the superficial femoral artery (SFA). In these cases, brachial and contralateral femoral approaches are usually preferred. However, when critical lesions or chronic total occlusions are simultaneously located above and below the knee, the recanalization of infragenicular vessels as well as of the pedal-plantar arch can be difficult in the absence of antegrade femoral access. The aim of the present study was to investigate the feasibility and efficacy of the treatment of ostial SFA lesions using the ipsilateral antegrade approach in patients presenting with CLI.
Section snippets
Study design and patient selection
This is a prospective evaluation of procedural and immediate clinical outcomes in a consecutive series of diabetic patients undergoing percutaneous transluminal angioplasty (PTA) for CLI with SFA lesions involving the vessel ostium. SFA lesions were defined as ostial if extending less than 1 cm from the origin of the vessel by visual estimation. Indication for peripheral angiography was taken according to “The Inter-Society Consensus; TASC II” [10]. PTA was performed in the same session as the
Results
From January 2010 to June 2011, 530 patients admitted to our institution with CLI underwent a lower limb angiogram, and in 452 patients, PTA was performed. The remaining 78 patients underwent bypass surgery (66 patients) or were judged not suitable for any kind of revascularization (12 patients). In the PTA group, 64 patients had ostial SFA lesions. According to the prespecified criteria, the brachial (four patients) or contralateral femoral approach (15 patients) was used in 19/64 (30%)
Discussion
The main findings of the present study are as follows:
- 1.
The antegrade approach can be safely performed in most patients (70%) presenting with CLI and ostial SFA lesions.
- 2.
The use of clinical and radiographic criteria correctly identifies patients with ostial SFA lesions suitable for the antegrade approach in 96% of cases.
- 3.
The antegrade treatment of ostial SFA lesions is associated with a high procedural success rate and a good safety profile.
The treatment of patients with CLI often requires the
Study limitation
There are some limitations of the present study. First, this is a single-arm study without a control group. Therefore, the rates of technical success and of vascular complications when routinely using the crossover approach were not assessed for comparison. Second, the results of the present study were derived from a single-center experience with a high work volume where the antegrade approach has been routinely adopted for many years as a first-choice approach. It is therefore likely that the
Conclusion
Ostial SFA lesions can be safely and effectively approached in an antegrade fashion if patients and lesions are correctly screened with duplex scan analysis and physical examination. The 19G bare needle angiogram of the femoral bifurcation correctly identifies an adequate puncture site in the vast majority of patients. The preference of antegrade puncture even in the case of ostial SFA lesions is justified by extremely frequent need of simultaneous treatment of above and below the knee arteries
References (16)
- et al.
Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003
Eur J Vasc Endovasc Surg
(2005) - et al.
Infrapopliteal angioplasty for critical limb ischemia: relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs
J Vasc Surg
(2008) - et al.
Subintimal angioplasty with the aid of a re-entry device for TASC C and D lesions of the SFA
Eur J Vasc Endovasc Surg
(2009) - et al.
Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)
Eur J Vasc Endovasc Surg
(2007) - et al.
Recommended standards for reports dealing with lower extremity ischemia: revised version
J Vasc Surg
(1997) - et al.
Two-year outcome with preferential use of infrainguinal angioplasty for critical ischemia
J Vasc Surg
(2006) - et al.
Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial
Lancet
(2005) - et al.
Medical and endovascular management of critical limb ischemia
J Endovasc Ther
(2009)
Cited by (5)
Ipsilateral Antegrade Angioplasty for Flush Superficial Femoral Artery Occlusion versus Open Bypass Surgery
2019, Annals of Vascular SurgeryCitation Excerpt :CTA was performed if clinical and duplex data detected restenosis or reocclusion. Flush occlusion is a chronic occlusion that starts at or less than 1 cm distal to the origin of the artery by visual estimation.14 The following definitions are in accordance with the revised reporting standards of the Society for Vascular Surgery for PAD and Rutherford guidelines.15,16
Duplex-Guided Ipsilateral Antegrade Approach for Flush Superficial Femoral Artery Occlusion
2023, Vascular and Endovascular SurgeryEndovascular intervention influshsuperficial femoral artery occlusive disease: Challenges and outcome
2019, Italian Journal of Vascular and Endovascular SurgeryCommentary: Self-Expanding Stentys System for Significant Infrapopliteal Stenoses: Rainbow Six?
2017, Journal of Endovascular TherapyRecent progress in endovascular treatment for diabetic lower extremity vascular disease
2015, Journal of Interventional Radiology (China)
- ☆
Conflict of interest: none.