Retrograde access revascularization in chronic limb threatening ischaemia

PURPOSE: Chronic limb-threatening ischaemia (CLTI) is associated with high rates of major amputation, mortality and comorbidity that can make conventional femoral access challenging or contraindicated; in particular in patients with recent groin surgery, infection, previous aorto-bifemoral stent reconstruction, hostile groins, or unfavourable body habitus. Tibio-pedal arterial minimally invasive retrograde revascularisation (TAMI) provides an alternative access strategy. MATERIALS AND METHODS: This retrospective single-centre cohort study included 84 TAMI procedures in 81 limbs from 77 patients with CLTI (median age 72 years; 64% male; Rutherford IV 22%; Rutherford V-VI 78%). TAMI was performed because of recent groin surgery/infection in 35% of procedures and patient-related factors in 65%. The primary clinical endpoint was freedom from major adverse limb events (MALE), defined as major amputation or clinically driven target-vessel reintervention (CDTVR). Secondary endpoints included technical success, defined as restoration of continuous inline flow through at least one infrapopliteal artery to the foot with < 50% residual stenosis on completion angiography, and access vessel safety. RESULTS: Retrograde access was obtained predominantly via the dorsalis pedis (71%) and distal posterior tibial arteries (16%). Technical success was achieved in 66/84 procedures (78%); in 10/84 (12%), TAMI access and lesion crossing were successful but the predefined angiographic endpoint was not met, while eight procedures (10%) were abandoned. Asymptomatic access vessel spasm was documented in 35/84 procedures (42%) that had resolved by 24 h. Among 68 patients (71 limbs) with longitudinal follow-up, median follow-up was 150 days (IQR 76-322). CDTVR occurred in 22/71 limbs (30%) and major amputation in 14/71 (20%); 25/68 patients (37%) died. Kaplan-Meier estimated freedom from MALE was 57.9% (95% CI 43.9-69.6%) at 6 months and 51.2% (95% CI 36.0-64.5%) at 12 months. In multivariable Cox regression analysis, none of the evaluated covariates was significantly associated with MALE. CONCLUSION: In this selected, anatomically complex CLTI cohort, TAMI was a feasible alternative access strategy when conventional femoral access was challenging or not feasible, with a low observed rate of clinically significant pedal access complications.