In recent months, there has been a focus on a retrograde approach to crossing lesions in Vascular Disease Management articles and blog posts. All of these sources show that in the rare cases where antegrade approaches fail or are impossible, retrograde strategies can be successful in crossing lesions and restoring blood flow.
In a two-part blog post series, Drs. Heuser and Mhatre present cases in which they used a retrograde approach to cross lesions. In the first case, Drs. Heuser and Mhatre intervened on the right tibioperoneal trunk artery by gaining access via the right posterior tibial artery.
“We felt it may be safer to attempt retrograde crossing first as opposed to antegrade crossing,” the authors write. “We thought that there was a risk of possible dissection via the antegrade access route, which would have therefore stopped blood flow to the lower leg.”
The second post, which includes video of angiograms pre- and post retrograde crossing, Drs. Mhatre and Heuser describe a case of a 50-year-old male who previously had poor results post intervention of a left superficial femoral artery chronic total occlusion. They elected to cross the occlusion retrograde, and post-intervention angiography showed a patent SFA (see “Retrograde Crossing: When the Front Door Is Locked, Part 2“).
In the June issue of VDM, Dr. George presents a case of revascularization using a retrograde technique in the Case Files by Dr. George column, “Retrograde Use of Re-Entry Catheter for Revascularization of Superficial Femoral Artery Chronic Total Occlusion.” An excerpt from the case description follows:
Percutaneous intervention of the right SFA CTO was initiated using left common femoral access with advancement of a 7 French Ansel sheath (Cook Medical) over an Amplatz stiff wire (Cook Medical) across the aortoiliac bifurcation into the right common femoral artery. Selective angiogram of the right common femoral artery revealed a 100% heavily calcified occlusion of the right SFA with reconstitution of the popliteal artery via collaterals from the profunda femoral artery and 3-vessel runoff into the right foot (Figure 1). Multiple attempts at revascularization via the antegrade approach were unsuccessful despite the use of CTO catheters, looped glidewires, and stiff wires repeatedly entering the subintimal space. However, the distance from the reconstituted vessel prevented the antegrade use of a re-entry catheter.
Next, the right popliteal artery was accessed using ultrasound guidance with a micropuncture access kit and a 2.9 French pedal access kit sheath (Cook Medical) (Figure 2) to define the distal occlusion cap by angiography. A SurePath guidewire (IDEV) was advanced in retrograde fashion up to the proximal SFA but entered a subintimal plane adjacent to the true lumen and was again unsuccessful in entering the true lumen secondary to heavy calcification. An Outback re-entry catheter (Cordis) was then advanced over the SurePath guidewire in the subintimal plane to the proximal superficial femoral artery (Figure 3).
And coming up in July, Dr. Jihad Mustapha will present a live webinar on tibiopedal arterial minimally invasive retrograde revascularization, or the TAMI technique. Dr. Mustapha is affiliated with Metro Health’s Metro Heart & Vascular in Wyoming, Michigan. The interventional cardiologists at Metro Heart & Vascular developed the TAMI technique, which enables access to arteries in the feet for patients who cannot lay flat for traditional procedures. The technique enables physicians to re-establish blood flow using balloons, stents, and drilling devices to remove plaque that is blocking blood flow. The TAMI procedure was developed for patients for whom traditional treatments posed too great a risk for complications – and is designed to help patients avoid amputation of the legs and feet.
Have you used a retrograde technique to cross a calcified lesion? Did you have success? Let us know in the comments below why you would or would not use this technique.