Lower extremity extracorporeal distal revascularization (LEEDR) as a novel approach to limb salvage following prolonged ischemia

Acute limb ischemia necessitates prompt revascularization to preserve viability and minimize systemic ischemia-reperfusion injury. Delays in care increase morbidity and mortality, underscoring the need for nonsurgical temporizing methods. Lower Extremity Extracorporeal Distal Revascularization (LEEDR) is a percutaneous technique that delivers oxygenated blood from the contralateral femoral artery to the ischemic limb via a retrograde tibial cannula. This study aimed to evaluate LEEDR compared to prolonged untreated warm ischemia. Anesthetized Yorkshire swine (40-60 kg) underwent hindlimb ischemia via endovascular balloon occlusion of the left external iliac and middle sacral arteries and were randomized to control (n = 6; 9 h ischemia) or LEEDR (n = 6; 1-h ischemia plus 8 h extracorporeal support). Revascularization was achieved by balloon deflation, followed by 48 h of observation. The primary outcome was survival; secondary outcomes included gait function, compartment pressure, and biochemical markers of ischemia-reperfusion injury. Survival was significantly higher in the LEEDR group (83% vs. 0%; p = .001). LEEDR animals demonstrated improved gait function (5.8 ± 0.34 vs. 2.5 ± 0.7; p < .001), lower compartment pressures (9.9 ± 1.7 vs. 28.5 ± 4.2 mm Hg; p < .001), and reduced serum potassium (4.57 ± 0.22 vs. 5.14 ± 0.54 mmol/L; p < .001) and lactate concentrations (1.4 ± 0.55 vs. 2.5 ± 1.6 mmol/L; p < .001) during reperfusion and recovery. LEEDR effectively mitigated the consequences of 9 h of warm ischemia in a swine model, improving survival, preserving limb function, and preventing compartment syndrome. This percutaneous technique may serve as a viable temporizing strategy in patients with delayed access to definitive revascularization.