الفهرس 
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Abstract
We conducted prospective, non-randomized, observational study that included 178 patients presenting with intermediate and advanced limb-threatening ischemia (WIFI stages 2-4) associated with significant perfusion deficits (WIFI ischemia grades 2-3), according to WIFI classification system, due to an infrainguinal CTO in whom a percutaneous tibiopedal access was attempted as a consequence of failed recanalization using an antegrade approach. There were 124/178 (69.7%) males and 54/178 (30.3%) females with a mean age of 64.1 ± 7.5 years. The most frequent risk factor was diabetes in 110/178 (61.8%), followed by smoking in 74/178 (41.6%), hypertension in 63/178 (35.4%), and dyslipidemia in 52/178 (29.2%). The most common indication for retrograde approach was failure to cross the occlusion from antegrade access, as encountered in 82 patients (46.1%) followed by failure to enter the occlusion in 57 patients (32%). Other indications included wire perforation and failure to reenter the true lumen from antegrade approach. The PTA followed by the proximal ATA were the most frequent vessels utilized for retrograde access in 86 (48.3%) and 68 (38.2%) patients, respectively. Fluoroscopy was used to guide the retrograde access in 115 patients (64.6%), while ultrasound guidance was in 63 patients (35.4%).Access success was obtained in 93.8% (167/178). The target vessel puncture was unsuccessful in 11 cases with subsequent failure of intraluminal wire delivery, and that was attributed to severe calcification at the target access site. Crossing success was reported in 95.8% (160/167) of successful retrograde access cases. For the remaining 7 cases, failure was owing to an inability to traverse the occlusion (3 patients), or enter the proximal true lumen (4 patients), with a subsequent procedure abortion.
The treatment applied after successful guidewire crossing and entrance into the proximal true lumen was standard balloon angioplasty in 132 patients (82.5%), while stenting was deemed necessary in 28 patients (17.5%). Treatment success was obtained in 158 (88.8%) of the cases in which retrograde access was tried. Complications were reported in 23 patients (23/178) (12.9%), including 17 (9.5%) tibiopedal access site complications. Vessel spasm at the distal access site was the most commonly encountered complication (8 patients, 4.5%) followed by tibiopedal access site hematoma in 4 patients (2.2%). Other rare complication included access site thrombosis and arteriovenous fistula. All patients were followed up for a mean period of 29.2 ± 4.0 months. Of patients who underwent successful recanalization using tibiopedal access, the primary, assisted primary, and secondary patency rates were 67.6% ± 3.6%, 78.2 ± 3.1%, and 82.8 ± 2.9% at 12 months, and 43.8% ± 3.9%, 64.2% ± 3.8%, and 71.7% ±3.5% at 24 months, respectively. Freedom from CD-TLR was 72.9% ± 3.4%, and 55.4% ± 3.9% at 12 and 24 months, respectively. Kaplan-Meier analysis yielded an overall limb salvage rate of 88.5% ± 2.4%, and 77.4% ± 3.3%, and AFS of 84.5% ± 2.7%, and 71.1% ±3.5% at 12 and 24 months, respectively. Multivariable Cox regression analysis revealed that diabetes, tissue loss, moderate to severe calcification, single runoff vessel, and GLASS stage III were significantly associated with loss of patency. Moreover, smoking, tissue loss, moderate to severe calcification, single runoff vessel, and GLASS stage III were independently related to worse AFS. Presentation with tissue loss, WIFI stage III-IV, and GLASS stage III were independent predictors of major amputation, while diabetic patients with single runoff vessel and GLASS stage III were independently related to overall mortality. According to this analysis of single-center data, retrograde tibiopedal access is an effective and safe approach as it is associated with high access, crossing, treatment success, and low complication rates. This approach adds to the armamentarium of endovascular procedures in recanalization of infrainguinal CTOs, after failed antegrade attempts, in patients with CLTI. Inability to enter the true lumen during an endovascular intervention involving infrainguinal CTO, was estimated to occur as high as 20% of cases, although this may be lower in more contemporary practice. Nonetheless, a retrograde pedal approach is another option for patients with CLTI. It can be achieved with minimal morbidity, avoiding the use of more expensive re-entry devices, and the present single-institutional series shows high access, crossing, treatment success, and low complication rates. More experience with this technique and further refinement are required for further improvements in the treatment of infrainguinal CTO lesions in patients with CLTI. Reports in the literature are still few, and there are no long-term results regarding the effects on limb salvage and quality of life measurements