Role of retrograde transpopliteal angioplasty for superficial femoral artery occlusion

1. Role of Retrograde Transpopliteal Angioplasty
for Superficial Femoral Artery Occlusion
Submitted by
Sameh Attia Ali Abd-Elhamid
(M.B., B.Ch. M.Sc. Vascular surgery Surgery, Egyptian board of vascular surgery,
MRCS)

2. Introduction
O Patients with lower extremity peripheral artery
disease (PAD) experience substantial functional
disability due to claudication, rest pain, and the
loss of tissue integrity in the distal limbs. The
number of patients requiring lower limb
revascularization for lower limb ischemia is likely
to increase significantly worldwide as a result of
aging populations, the increasing prevalence of
diabetes, and the so far failure to significantly
reduce global tobacco consumption (Zeller, 2007).

3. O Lower extremity occlusive disease may
range from exhibiting no symptoms to limb-
threatening gangrene. There are two major
classifications developed based on the clinical
presentations are Rutherford and fontaine
classifications, These clinical classifications
help to establish uniform standards in
evaluating and reporting the results of
diagnostic measurements and therapeutic
interventions (Norgren et al., 2007).
Introduction

4. Introduction
O Although bypass surgery has been the standard
method of revascularization because long-term
patency can be achieved, this approach also can be
difficult for certain patients because of poor
surgical targets, lack of suitable conduits,
advanced age, and presence of multiple
comorbidities, also endovascular therapy offers the
advantages of local anesthesia and shorter hospital
stay. Initial studies suggested similar outcomes for
these two strategies, especially among patients
with a life expectancy of less than 2 years (Singh
et al., 2014).

5. Introduction
O EndoVascuar Treatment (EVT) for
Superficial Femoral Artery (SFA) are
generally managed by the antegrade approach,
which uses a contralateral retrograde puncture
or ipsilateral antegrade puncture of the
common femoral artery. Alternatively, the
popliteal approach is less frequently utilized
(Bakalarz et al., 2017).

6. Introduction
O In about 20 to 30% of the cases standard
techniques including the cross-over and the
antegrade approach fail to cross total
superficial femoral artery occlusions. In these
cases, the transpopliteal technique can be used
as secondary approach after failed cross-over
recanalization. Furthermore, long superficial
femoral artery occlusions without visible
patent proximal stump can be recanalized
using this technique (Bray et al., 2003).

7. Introduction
O The principle reasons for standard
endovascular procedural failure are the
inability to remain intraluminal during
crossing the CTO segment, and re-entering the
true lumen. There is also an associated risk of
perforation, dissection and creation of
arteriovenous fistulas (Saxon et al., 2007).

8. Introduction
O The popliteal approach, first reported by
Tonnesen et al. in 1988 and initially
performed with patients in a prone position,
has been associated with complications such
as dissections, arterial ruptures, arteriovenous
fistula, pseudoaneurysms, bleeding, and
hematomas, making it less popular than the
antegrade approach (Ueshima et al., 2015) .

9. Introduction
O Furthermore, to avoid changing a patient’s
position, popliteal puncture with patients lying in
the supine position has been reported. In addition,
the use of smaller-diameter puncture instruments,
such as 3 Fr sheaths or microcatheters, instead of
the conventional 4–6 Fr sheaths, has been
attempted. With the use of these modifying
techniques, the aim is to reduce complications and
the nuisance of popliteal puncture, and it has since
gained popularity (Tokuda et al., 2014).

10. Aim of the work
O The aim of the study is to evaluate the
effectiveness and safety of the retrograde
popliteal approach for recanalization of long
segment occlusion of superficial femoral
artery in cases with chronic lower limb
ischemia (Rutherford 3,4,5 and 6) .

11. patient and methods
O Inclusion criteria:
 Patients with chronic lower limb ischemia Rutherford categories 3, 4,
5 and 6 (severe claudication, ischemic rest pain, minor tissue loss and
major tissue loss).
 All patients should have proximal SFA long total occlusion.
 All lesions could not be crossed through the antegrade access either
by the ipsilateral or by the contralateral femoral approach.
 All patients have patent popliteal artery distal to the SFA occlusion.

12. patient and methods
O Exclusion criteria:
 Acute on top of chronic ischemia of the lower limb.
 Limbs requiring primary amputations.
 Stenotic SFA lesions.
 All arterial lesions associated with A-V malformation.
 All arterial lesions associated with aneurysmal dilatation.
 Connective tissue disorders or immunological disease
 Sensitivity to the dye used in angioplasty.
 Patient refusal.

13. methods
O (I) Clinical assessment:
O History taking and clinical examination was done for all patients including:
1. Age and gender.
2. Major risk factors for atherosclerosis
3. Clinical assessment of the patient, degree of ischemia, tissue, gangrene, motor power,
sensory loss and degree of paresthesia, coldness, capillary circulation, color changes,
and pulsations.
O (II) Pre-procedural investigations:
 Routine laboratory tests:
 Duplex scanning.
 CT angiography.
 Echocardiography
 X ray foot

14. Technique of endovascular management
O Pre-procedure preparation:
O All patients were admitted to the hospital at day of or 24 hours
before the procedure and the following measures were taken:
 Monitoring the medical condition of patients with medical illness
 For ESRD patients dialysis was scheduled one day pre procedure and
same day post procedure.

15. O Endovascular Procedure:
 Interventions were performed in an angiography suite. All patients received
5000 units of heparin prior to PTA.
 Proper hydration was ensured by adequate fluid intake the day before the
procedure, N-acetyl cysteine 600mg was given in pre and postprocedurally.
 75 mg of clopridogrel, 150 mg of aspirin and 20 mg of Atorvastatin were
maintained for at least 30 days post intervention. Low dose aspirin was
continued indefinitely.
 The patients were instructed to ensure the cleanliness of both groins.
 All equipment was checked; Sheaths, wires, catheters and balloons of different
sizes were prepared. The patient lied in the supine position.
 An antiseptic solution (Betadine) used to disinfect the groin area and sterile
towels were placed over the patient.
 For all cases a local anesthetic (Xylocaine 2%) was used. The dose varied
between 10 ml to 20 ml.

16. PREOPERATIVE DUPLEX & CT
ANGIOGRAPHY

17. PREOPERATIVE DUPLEX & CT
ANGIOGRAPHY

18. PREOPERATIVE DUPLEX & CT
ANGIOGRAPHY

19. ACCESS

20. ACCESS

21. ACCESS

22. ACCESS

23. ACCESS

24. WIRE

25. WIRE

26. WIRE

27. PTA

28. PTA

29. PTA

30. PTA

31. PTA

32. PTA

33. PTA

34. COMPLETION ANGIOGRAPHY

35. COMPLETION ANGIOGRAPHY

36. COMPLETION ANGIOGRAPHY

37. PROCEDURAL OUTCOME
 Technical success, defined as puncture of the popliteal
artery and recanalization of the SFA were achieved.
O Clinical success which may be:
 Definitive success in the form of (regaining of pulse,
revascularization warmness, edema and disappearance
of rest pain).
 Clinical improvement (good capillary circulation,
warmth, relief of symptoms and good healing of ulcer
or minor amputation).
 Angiographic success defined as less than 30% residual
stenosis measured at the narrowest point of arterial
lumen.
 The mean ankle-brachial index measurements were
done.

38. Post-Procedural managment
O The arterial sheath was routinely removed 2-3 hours after
the procedure. Digital compression was done for15-
20minutes.
O Post procedural all patients will be medicated on
therapeutic low molecular weight heparin (LMWH)
anticoagulation for 48 hrs.
O Most patients were discharged on the second day following
the procedure after receiving instructions on risk factors
control and treatment including: aspirin 150 mg/ day for life,
clopidogrel 75 mg/ day for at least one month and
atorvastatin according to the presence or absence of
dyslipidemia

39. RESULTES
O Table (1): Age distribution among
studied cases (n=30)
Age
Mean 65.13±3.69
Range (60.0-73.0)

40. RESULTES
Table (2): Sex distribution
N %
Sex Male 22 73.3
Female 8 26.7
Total 30 100.0
73.30%
26.70%
Sex
Male
Female

41. RESULTES
Table (3): SFA length distribution
SFA
Mean±
SD
96.2±4.5
Range (81.70-107.0)

42. RESULTS
Table (4): ABI distribution and change between pre
and post transpopliteal retrograde recanalizaiom of
SFA
Pre Post Paired t P
ABI 0.48±0.05 0.7±0.06 -16.15 0.00**

43. RESULTS
O Table (5): Patients characters and risk factors
N %
Smoking Not
smokin
g
10 33.3
Smoki
ng
20 66.7
DM Non 18 60.0
Diabeti
c
12 40.0
HTN Not 17 56.7
Hypert
ensive
13 43.3
CHD NO 24 80.0
CHD 6 20.0
Hyper-
cholesrolemia
No 14 46.7
Yes 16 53.3
Total 30 100.0

44. RESULTES
O Table (6): Retrograde recanalization of
SFA
N %
6 Fr sheath 8 26.7
4 Fr sheath 10 33.3
Double balloon 12 40.0

45. RESULTES
O Table (7): Stent used distribution
N %
Yes 12 40.0
No 18 60.0

46. RESULTS
O Table (8): Post-operative complication
N %
No 25 83.3
Popliteal artery Pseudo-aneurysm 3 10.0
Fistula between popliteal artery and vein 2 6.7

47. RESULTES
O Table (9): Patency of superficial femoral
artery
N %
PATENCY_6M No 6 20.0
Yes 24 80.0
PATENCY_1YE
AR
No 7 23.3
Yes 23 76.7
Total 30 100.0

48. RESULTS
Table (10): Association between patency and patients
characters and risk factors

49. RESULTS
Table (11): patency relation with age, SFA distribution and
ABI:
Patent Significantly higher regard ABI post
Patent Not T P
Age 64.78±3.42 66.28±4.49 -0.941 0.355
SFA 96.14±5.11 96.38±1.52 -0.120 0.905
ABI_PRE 0.48±0.054 0.47±0.07 0.601 0.553
ABI_POST 0.72±0.04 0.6±0.0 7.544 0.000

50. CONCLUSION
O In conclusion, retrograde popliteal approach is feasible, safe, and
effective technique for the management of chronic superficial femoral
artery occlusion in patients with failure of passing through the antegrade
access either by the ipsilateral or by the contralateral femoral approach.
The retrograde popliteal approach achieved a clinically relevant primary
patency rate with low incidence of complications. Nevertheless, further
large-scale studies are still needed to confirm our findings.

51. Thankyou