Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 42-47

Retrograde popliteal approach for endovascular revascularization of flush superficial femoral artery chronic total occlusion: A two-center experience


1 Department of Cardiothoracic and Vascular Surgery, Uttar Pradesh University of Medical Sciences, Saifai, India
2 Department of Cardiothoracic and Vascular Surgery, LPS Institute of Cardiology and Cardiothoracic Surgery, Kanpur, India
3 Department of Cardiothoracic and Vascular Surgery, RML Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission16-Mar-2020
Date of Decision21-Apr-2020
Date of Acceptance02-Jun-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
Ajitesh Princy Jain
Department of Cardiothoracic and Vascular Surgery, RML Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_27_20

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  Abstract 


Introduction: Chronic total occlusions (CTO) of the superficial femoral artery (SFA) are generally managed by an endovascular retrograde contralateral “crossover” or ipsilateral antegrade common femoral artery (CFA) approach. In cases with flush occlusion or a very short SFA stump at common CFA bifurcation, antegrade recanalization frequently fails due to an inability to engage the true ostium of the SFA. The purpose of this study was to evaluate the efficacy and safety of retrograde popliteal approach for endovascular revascularization of flush SFA CTO. Materials and Methods: We retrospectively investigated 18 patients (14 males and 4 females, mean age 61 ± 14 years) with flush SFA CTO undergoing retrograde popliteal artery (PA) revascularization at two endovascular centers in North India between January 2017 and December 2018. All the patients had critical limb ischemia (CLI) and flush SFA CTO with ostial involvement. Hemostasis was achieved by the manual compression only. Study endpoints were technical success rate, puncture site complications, and limb salvage. Results: CLI with Rutherford category 5 dominated the clinical presentation (56%) with most of the patients presenting late after disease onset. Majority were Trans-Atlantic Inter-Society Consensus-C (72%) chronic SFA occlusions (mean lesion length 185 ± 52 mm). Doppler-guided popliteal puncture and sheath placement were successful in 100%. Technical success rate of retrograde revascularization was 83%. Intraluminal recanalization was possible in 56% from the popliteal access, and subintimal recanalization was done in 28%. There was no major access site-related complication or mortality in the follow-up period. The primary patency rates at 6 months and 1 year postintervention were 93% and 80%, respectively. Conclusions: Retrograde PA approach under Doppler guidance was effective in terms of technical success rate of popliteal puncture as well as retrograde revascularization of flush SFA CTO. The approach was safe with no major access site complications.

Keywords: Popliteal approach, retrograde superficial femoral artery revascularization, superficial femoral artery flush occlusion


How to cite this article:
Singh A, Prakash N, Kumar N, Jain AP, Verma R, Krishna V. Retrograde popliteal approach for endovascular revascularization of flush superficial femoral artery chronic total occlusion: A two-center experience. Indian J Vasc Endovasc Surg 2021;8:42-7

How to cite this URL:
Singh A, Prakash N, Kumar N, Jain AP, Verma R, Krishna V. Retrograde popliteal approach for endovascular revascularization of flush superficial femoral artery chronic total occlusion: A two-center experience. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Mar 1];8:42-7. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/42/309706




  Introduction Top


Chronic total occlusions (CTO) of the superficial femoral artery (SFA) are generally managed endovascular by a retrograde contralateral “crossover” or ipsilateral antegrade common femoral artery (CFA) approach.[1] In cases with flush occlusion or a very short-SFA stump at CFA bifurcation, antegrade recanalization frequently fails due to an inability to engage the true ostium of the SFA.[1],[2] In such cases, retrograde revascularization can be performed through retrograde popliteal artery (PA) approach. The retrograde popliteal approach was initially considered a “back-up” plan due to associated complications such as arteriovenous fistula, dissections, pseudoaneurysms, bleeding, and hematoma.[3] It has emerged as an effective alternative technique and even a preferred approach for selected patients. The purpose of this study was to evaluate the efficacy and safety of retrograde popliteal approach for endovascular revascularization of flush SFA CTO.


  Materials and Methods Top


We retrospectively investigated 18 patients (14 males and 04 females, mean age 61 ± 14 years) with flush SFA CTO undergoing retrograde PA revascularization at two endovascular centers in North India between January 2017 and December 2018. The procedure was explained to all the patients, as well as the possible complications, and written informed consents were obtained.

Indications for endovascular approach were technical inoperability by open surgery, coexistent significant iliofemoral or infrapopliteal lesions or unsuitable veins for grafting. Indication for popliteal access was failed antegrade recanalization due to an inability to engage the true SFA ostium. The exclusion criteria were acute total occlusions, obesity, and pulmonary disease.

All the patients had critical limb ischemia (Rutherford category 4–6) and flush SFA CTO with ostial involvement (Trans-Atlantic Inter-Society Consensus [TASC] – B, C and D lesions, mean occlusion length 185 ± 52 mm). The cases with TASC-D femoropopliteal lesions (n = 02) had a patent PA P3 segment amenable to puncture for sheath placement. Cases with coexistent significant below-the-knee (BTK) disease (n = 06) were also included; these were approached by ipsilateral antegrade femoral approach in a staged manner 2–4 weeks after the SFA revascularization, if indicated. Most of the patients were on dual anti-platelet therapy (DAPT) comprising ecospirin 150 mg plus clopidogrel 75 mg and cilostazol 100 mg for at least 2 months preintervention with no symptomatic improvement.

All patients were followed up at regular intervals (weekly for a month, fortnightly for 3 months, and then at 6 and 12 months) with clinical assessment and ABI measurement. Duplex imaging of the target lesion and the access site was done only in patients with ischemic symptoms or access site swelling. Study end points were the technical success rate of popliteal puncture (defined as successful Doppler-guided popliteal puncture and sheath placement), technical success rate of retrograde revascularization (defined as fluoroscopy guided successful wire negotiation across the occlusion and angioplasty with residual stenosis ≥30%), puncture site complications and limb salvage (defined as avoidance of a major amputation above the level of the ankle joint).

Intervention procedure

Endovascular procedures were performed in a dedicated angiographic suite under local anesthesia, sterile draping, and continuous monitoring. Loading dose of ecospirin 300 mg plus clopidogrel 150 mg was given 2 h before the procedure to all the patients who were not on DAPT preoperatively for at least a week. All the procedures began with the patient in the supine position. CFA access was gained for retrograde contralateral “crossover” approach in all patients (5F, 11 cm long introducer sheath; “Input,” Medtronic). Selective common iliac arteriography and/or digital subtraction angiography was obtained to delineate the lesions [Figure 1]a and [Figure 1]b. Heparin was given intraarterially to maintain an activated clotting time of 200–250 s.
Figure 1: (a and b) Digital subtraction angiography revealing flush chronic total occlusions of Rt. Superficial femoral artery with reconstitution of mid-superficial femoral artery and popliteal artery (P1 segment) through collaterals with significant coexistent ipsilateral lesions in common femoral artery and external iliac artery

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Failure to negotiate the guidewire across the SFA occlusion antegradely, despite multiple attempts with various guidewire/support catheter combinations, required conversion to a retrograde PA approach. The femoral sheath was fixed to the skin and patient was turned into a prone position. Sterile draping and exposure of popliteal fossa were done.

Under USG guidance, PA was assessed in transverse section, local anesthesia (2% lignocaine) was given along the proposed track, puncture was made (distal P2 or proximal P3 segment) with micropuncture needle in medial to posterolateral direction, at an angle of 45°-60° with skin surface, taking care to avoid popliteal vein puncture. After verification of the correct position of wire under fluoroscopy, 5F femoral sheath was placed, followed by angiography of the PA and infrapopliteal arteries. After assessing the distal SFA, the next step was to negotiate the occlusion from its distal end with a hydrophilic 0.035” Glidewire (Terumo), supported by a 4F MPA diagnostic catheter or a percutaneous transluminal angioplasty (PTA) balloon catheter. Intraluminal negotiation of the SFA CTO was attempted in all the patients with various guidewires (”Radiofocus,” Terumo; “Magic torque, V-18” Boston Scientific) with catheter support. In cases with failed intraluminal negotiation, subintimal tracking of the wire was attempted (n = 08) [Figure 2].
Figure 2: Subintimal tracking of guidewire by popliteal approach, after failed intraluminal negotiation, with patient in the prone position

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After successful crossing of the CTO, intraluminal position of the catheter tip was verified by contrast injection and then exchanged with appropriate 5F compatible noncompliant PTA balloon catheter (”Mustang,” Boston Scientific), angioplasty done retrogradely from the popliteal access site itself with inflation at nominal pressure for 2 min. 5F compatible self-expanding peripheral stents (”Everflex,” Medtronic) were deployed in the event of suboptimal angioplasty or flow limiting flap/dissection. 5F femoral sheath was used in all the patients which was the preferred route for every retrograde intervention performed (angioplasty ± stenting). After completion angiography, the popliteal sheath was removed and manual compression applied for 10 min, followed by a nonocclusive pressure bandage for a day.

In patients with a patent profunda femoris artery (PFA) supplying distally with collaterals (n = 08), attempts were made to safeguard the ostium. A 0.018” PTA wire (”V18,” Boston Scientific) was placed in the PFA from the contralateral crossover CFA access, followed by adequately sized PTA balloon (”Sterling,” Boston Scientific) positioned in the ipsilateral PFA extending into CFA, before turning the patient to the prone position. Simultaneous inflation of the SFA and PFA balloons, in a “kissing” manner, was done to prevent any plaque shift or embolization into the patent PFA. PTA of significant coexistent ipsilateral iliofemoral lesions, with near congruent arterial diameters, was done with the same balloon used for SFA angioplasty, because of economic issues [Figure 3]a and [Figure 3]b. Good antegrade flow ensured up to the PA and BTK [Figure 4]a and [Figure 4]b. Significant coexistent BTK lesions (n = 03) were approached by ipsilateral antegrade femoral approach in a staged manner after 2–4 weeks.
Figure 3: (a and b) Simultaneous inflation of the superficial femoral artery and profunda femoris artery balloons, in a “kissing” manner, percutaneous transluminal angioplasty of coexistent ipsilateral iliofemoral lesions with the same superficial femoral artery balloon

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Figure 4: (a and b) Postprocedure good antegrade flow in the superficial femoral artery, profunda femoris artery and Pop. A

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Post procedural care: DAPT (tablet ecospirin 150 mg plus clopidogrel 75 mg) for 12 weeks followed by ecospirin 150 mg thereafter. Cilostazol was continued in patients with significant coexistent BTK disease. Aggressive risk factor modification therapy for diabetes, hypertension, dyslipidemia, smoking, and sedentary lifestyle was advised. Wound care protocol was strictly adhered to. Clinical examination was done the day after the procedure (after removal of the compression bandage) and duplex imaging of the access site was done before discharge in all the patients. Conservative amputations of the gangrenous feet were done after the establishment of clear line of demarcation. All patients were followed up at regular intervals (weekly for a month, fortnightly for 3 months, and then at 6 and 12 months) with clinical assessment and ABI measurement. Duplex imaging of the target lesion and the access site was done only in patients with ischemic symptoms or access site swelling.


  Results Top


Between January 2017 and December 2018, 18 patients (14 males and 4 females; mean age 61 ± 14 years) underwent retrograde PA revascularization for flush SFA CTO at two endovascular centers in North India.

Among the cardiovascular risk factors, smoking/tobacco chewing was associated in 72%, highlighting this significant health problem in our country. Rutherford category 5 (56%) dominated the clinical presentation at our center with most of the patients presenting late after disease onset. Of the 06 patients with Rutherford category 6 clinical presentation, 02 had gangrene of the foot and distal leg. Majority of the SFA lesions were TASC-C (72%) with coexisting significant ipsilateral iliofemoral or BTK disease [Table 1].
Table 1: Baseline patient characteristics

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Technical success rate of popliteal puncture was 100%. The average time for creating a retrograde popliteal access was 4 min (range 2–6 min).

Technical success rate of retrograde revascularization was 83%. 5F femoral sheath was used in all the patients which was the preferred route for all retrograde interventions performed (angioplasty ± stenting). Intraluminal negotiation of the occlusion was attempted initially in all the patients failing which subintimal tracking of the wire was attempted (n = 06). Stents were deployed in the event of suboptimal angioplasty or flow limiting dissection (2 patients each) [Table 2].
Table 2: Angiographic and procedural data

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All the 5 patients with coexistent ipsilateral iliofemoral disease underwent PTA of the lesions with the same balloon used for SFA angioplasty, 1 patient required stenting of the ipsilateral common iliac artery as well which was delivered by the popliteal approach.

Out of 6 patients with significant coexistent BTK disease, 3 patients showed increased BTK flow and healing of foot ulcers without any add-on BTK revascularization procedure. The other 3 patients required BTK revascularization by ipsilateral antegrade femoral approach in a staged manner after 2–4 weeks for optimal limb salvage.

There was minor bleeding in a patient 2 h after sheath removal which was controlled by recompression and application of compression bandage overnight. Two patients had minor hematoma over the puncture site detected before discharge which resolved conservatively. Two cases with minor infection surrounding puncture site were treated with oral antibiotics. There was no major access site related complication. There was no thrombosis, pseudoaneurysm, arteriovenous fistula, or neuropathy associated with popliteal puncture [Table 3].
Table 3: Access-site complications

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During the follow-up period of 19.2 ± 7.2 (range 12–26) months, the ABI increased from an initial 0.42 ± 0.16 at admission to 0.96 ± 0.18 at discharge and was 0.92 ± 0.19 at 6 months and 0.89 ± 0.18 at 12 months. The symptoms improved postprocedure with subjective improvement in rest pain. Toe ulcers healed in all the patients; 12 patients underwent limited amputation of the gangrenous toes and forefoot with successful stump healing, 01 patient underwent Syme's amputation and another one underwent high BTK amputation.

The primary patency rates at 6 months and 1-year postintervention were 93% and 80%, respectively. There were two in-stent restenosis and one occlusion in the follow-up period which were managed by reintervention. Secondary patency rate was 93% at 18 months. There was no mortality in the study group.


  Discussion Top


The SFA occlusions are generally managed by retrograde contralateral “crossover” or antegrade ipsilateral approach and intraluminal or subintimal recanalization.[1] The retrograde popliteal approach, initially considered a “back-up” plan due to certain limitations, has emerged as an effective alternative technique and even a preferred approach for selected patients.[1],[2],[3] The main indications for this technique are flush SFA occlusion, a short SFA stump, tandem CFA/SFA lesions, and failure of the antegrade approach.[1],[3] It has been postulated that negotiation of guidewire from below-up may be more successful given the less severe fibrosis or calcification at the distal part of the occlusion.[4]

The popliteal approach, first reported by Tønnesen et al., was performed initially with patients in the prone position.[5] It has been associated with complications such as arteriovenous fistula (due to the proximity of the artery and vein at the popliteal fossa), dissections, pseudoaneurysms, bleeding, or hematoma after sheath removal.[6] The need for repositioning the patient to the supine position during the procedure, after popliteal puncture in prone position, and the potential risk of access site-related complications, have come in the way of wider acceptance of this procedure.[7] To avoid changing a patient's position, popliteal puncture with the patient in the supine position has been reported. Accessing the PA in the supine position, by flexing and rotating the knee medially, allows simultaneous manipulation of guidewires and balloons from above and below, allowing the use of SAFARI technique which can be improve the technical success rate.[8],[9] Hemostasis at the popliteal puncture site by manual compression is not entirely fool proof in the supine position and may require intraluminal tamponade by an inflated balloon or a closure device, increasing procedure time as well as cost. In our series, all the popliteal punctures were done with the patient in the prone position and hemostasis after sheath removal was done only by manual compression for 10 min with excellent results.

To reduce puncture-related complications, the use of lower profile 3–4 Fr sheaths and sheath less approaches have been described, but these necessitate snaring the guidewire, after negotiating the CTO, from a proximally placed 5–6 Fr sheath.[8],[10] This again increases procedure time, cost, and radiation exposure. The PTA is then performed through the usual retrograde contralateral “crossover” or ipsilateral antegrade approach. In patients with coexistent iliofemoral occlusions, ipsilateral or contralateral CFA access may not be feasible. Furthermore, coexistent aortic bifurcation disease or acute angulation may render the contralateral access technically demanding or even impossible to achieve.

An important fact is that most of the patients at our health system setup present late after disease onset (Rutherford category 5 and 6 patients [89%] dominated the clinical presentation at our center). Most of these patients are initially managed by general specialities at primary and community health centers, who start them on DAPT, and manage them conservatively by regular wound dressing and culture-directed antibiotics. The patients are referred to tertiary centers with vascular surgical and intervention facilities from primary and community health centers after many months of conservative management fail and they develop frank gangrene. In fact, many such cases are referred to vascular units for Doppler study and deciding the level of amputation! Second, for economic reasons, patients often prefer conservative management despite being informed about the prognosis and usefulness of all modalities. Continuous efforts by vascular societies in the form of awareness campaigns and representations to governmental policy-making bodies, focussed toward addressing this lacuna, are showing encouraging results.

As demonstrated in our series, with the advent of new generation low-profile balloons compatible with 4 and 5 Fr sheaths and stents deliverable by 5 Fr sheaths, PTA can be performed comfortably, safely and effectively from the popliteal access site itself. Significant coexistent ipsilateral iliofemoral lesions can be angioplastied with the same-balloon catheter used for SFA angioplasty through the retrograde PA approach. Infrapopliteal lesions can be dealt with in a staged manner after addressing the inflow disease.

Initially, in our series, in patients with patent PFA with collaterals, a 0.018” PTA wire was positioned in the vessel from the contralateral “crossover” approach to maintain an access in case of embolization. Earlier in the series, plaque shift occluding the patent PFA ostium occurred in a patient and another patient had embolization of the PFA post-SFA angioplasty, both of which were managed by PFA angioplasty over the preplaced wire after turning the patient to the supine position. Later in the series, all such cases were routinely managed by simultaneous inflation of preplaced PFA balloon during retrograde SFA angioplasty, in a “kissing” manner, protecting the PFA ostium. This maneuver prevented any subsequent incidence of plaque shift or embolization into the patent PFA.

Our initial attempt was intraluminal negotiation of guidewire, failing which subintimal intervention was tried. In two cases with attempted subintimal negotiation, reentry into the true lumen proximally failed, despite all maneuvers. The use of reentry devices, unavailable at our region, could have made a difference.

This can be the preferred route for SFA revascularization in selected cases.[11],[12] In patients with flush occlusion of both SFA and PFA or occlusion of ipsilateral CFA and SFA with no flow in the PFA, only a single retrograde access through PA with the patient in the prone position was established, without any antegrade access or attempt in supine position, and successful revascularization was performed.

There were certain limitations to our study. This was a retrospective, observational study with strict inclusion criteria leading to a small sample size. The pre- and postprocedure medical management protocol was not uniform; it was rather tailored to specific patient profile. Patient's poor compliance with postprocedure treatment and persistent tobacco consumption, which is a significant health problem in North India, could have influenced the primary patency rate. More study is required to assess the long-term outcomes of SFA PTA by “standalone” retrograde popliteal access.


  Conclusions Top


Retrograde PA approach under Doppler guidance was effective in terms of technical success rate of popliteal puncture as well as retrograde revascularization of flush SFA CTO. The approach was safe with no major access site complications. With competitive immediate and mid-term results, it can be considered the primary revascularization strategy in these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brountzos EN, Moulakakis KG, Avgerinos ED, Dalainas I, G Giannakopoulos T, Kakisis J, et al. Retrograde transpopliteal approach of iliofemoral lesions. Vasc Endovascular Surg 2011;45:646-50.  Back to cited text no. 1
    
2.
Schmidt A, Bausback Y, Piorkowski M, Werner M, Bräunlich S, Ulrich M, et al. Retrograde recanalization technique for use after failed antegrade angioplasty in chronic femoral artery occlusions. J Endovasc Ther 2012;19:23-9.  Back to cited text no. 2
    
3.
Pappy R, Hennebry TA, Abu-Fadel MS. Retrograde access via the popliteal artery to facilitate the re-entry technique for recalcitrant superficial femoral art?ery chronic total occlusions. Catheter Cardiovasc Interv 2011;78:625-31.  Back to cited text no. 3
    
4.
Fanelli F, Lucatelli P, Allegritti M, Corona M, Rossi P, Passariello R. Retrograde popliteal access in the supine patient for recanalization of the superficial femoral artery: Initial results. J Endovasc Ther 2011;18:503-9.  Back to cited text no. 4
    
5.
Tønnesen KH, Sager P, Karle A, Henriksen L, Jørgensen B. Percutaneous transluminal angioplasty of the superficial femoral artery by retrograde catheterization via the popliteal artery. Cardiovasc Intervent Radiol 1988;11:127-31.  Back to cited text no. 5
    
6.
Noory E, Rastan A, Schwarzwälder U, Sixt S, Beschorner U, Bürgelin K, et al. Retrograde transpopliteal recanalization of chronic superficial femoral artery occlusion after failed re-entry during antegrade subintimal angioplasty. J Endovasc Ther 2009;16:619-23.  Back to cited text no. 6
    
7.
Villas PA, Cohen G, Goyal A, Putnam SG 3rd, Ball D. The merits of percutaneous transluminal angioplasty of a superficial femoral artery stenosis via a retrograde popliteal artery approach. J Vasc Interv Radiol 1999;10:325-8.  Back to cited text no. 7
    
8.
Kawarada O, Yokoi Y. Retrograde 3-French popliteal approach in the supine position after failed antegrade angioplasty for chronic superficial femoral artery occlusion. J Endovasc Ther 2010;17:255-8.  Back to cited text no. 8
    
9.
Spinosa DJ, Harthun NL, Bissonette EA, Cage D, Leung DA, Angle JF, et al. Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interv Radiol 2005;16:37-44.  Back to cited text no. 9
    
10.
Tokuda T, Hirano K, Muramatsu T, Tsukahara R, Nakano M. A sheathless retrograde approach via the popliteal artery is useful and safe for treating chronic total occlusions in the superficial femoral artery. J Endovasc Ther 2014;21:289-95.  Back to cited text no. 10
    
11.
Yilmaz S, Sindel T, Ceken K, Alimoglu E, Lüleci E. Subintimal recanalization of long superficial femoral artery occlusions through the retrograde popliteal approach. Cardiovasc Intervent Radiol 2001;24:154-60.  Back to cited text no. 11
    
12.
Conrad MF, Cambria RP, Stone DH, Brewster DC, Kwolek CJ, Watkins MT, et al. Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: A contemporary series. J Vasc Surg 2006;44:762-9.  Back to cited text no. 12
    


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