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• W4229535703 abstract "Study DesignA retrospective, single-center study was performed of patients treated at an office-based laboratory (OBL) between January 2013 and November 2017.Key FindingsOf 237 patients with lower extremity arterial occlusive disease, the lesions could not be crossed from an antegrade approach in 39 patients (17%). Of these 39 patients, 14 were then treated using a retrograde distal approach. Although successfully treated, these 14 patients received significantly higher contrast doses with a significantly longer operative time and greater treatment costs compared with those treated by an antegrade approach.ConclusionsAlthough the operative times, costs, and radiation and contrast dose were greater with retrograde arterial access, it represents a safe and effective method for crossing chronic total occlusions (CTOs) in an OBL.CommentaryMost commonly an antegrade approach from the contralateral common femoral artery is used to cross a lower extremity arterial CTO. However, this approach fails to cross the occlusion in approximately one fifth of patients. A prospective, multicenter study analyzed the retrograde approach in the hospital setting and showed very high rates of successful access and lesion crossing with low complication rates. The retrograde access approach is based on the belief that the distal end of the CTO is often softer than the proximal cap. The technique involves using ultrasound or fluoroscopic guidance to insert a micropuncture 21-gauge needle with a 0.018-in. wire, followed by a 2.9F microcatheter. A Glidesheath Slender (Terumo Medical Corp, Somerset, NJ) is the authors’ sheath of choice. After successful retrograde crossing, the procedure was always converted to an antegrade approach by either cannulation of the existing antegrade groin sheath with the distal wire or using a three-lobe snare (EN Snare Endovascular Snare System; Merit Medical, Jordan, Utah) to deliver the distal wire to the antegrade groin access. Distal access was attained via the popliteal (n = 5), anterior tibial (n = 5), posterior tibial (n = 3), and dorsalis pedis (n = 1) artery. I agree with the authors that retrograde access should most often be used in patients with limb-threatening ischemia and not in claudicants. Nonetheless, almost one third of patients who had underwent retrograde access in this series were treated for claudication.I have three issues with this article. First, although the authors had a very low rate of access-related complications, a retrograde approach can traumatize the accessed distal artery, possibly rendering this vessel unsuitable for possible bypass in the future. Second, I have concerns about performing these complicated, distal-access procedures in an OBL, which the authors assured us is safe. OBLs are an alternative to hospital-based vascular care, and the increase in the number of endovascular procedures performed at these sites has been exponential. We reported our initial experience at a nonhospital-based ambulatory surgical facility and documented that 3% (5 of 167) of patients required emergent transfer to our hospital.1Pineda D. Tyagi S. Troutman D.A. Dougherty M.J. Calligaro K.D. Safety of out-patient endovascular procedures in a non-Hospital based facility.Vasc and Endovasc Surg. 2019; 53: 441-445Crossref PubMed Scopus (2) Google Scholar I urge caution about performing endovascular procedures in high-risk patients in OBLs, regardless of whether an antegrade or retrograde approach is used. The authors’ seemed to offer contradictory statements regarding performing these procedures at OBLs according to the American Society of Anesthesiologists scores. Third, it is my (unverified) impression based on reading the literature that many interventionalists who perform endovascular procedures at an OBL favor the use of atherectomy. Rotational atherectomy was used in 13 of the 14 patients in this series (and intravascular ultrasonography was also used in the vast majority). Reimbursement for atherectomies performed in an OBL are exceedingly high. I wonder if there is a correlation. Study DesignA retrospective, single-center study was performed of patients treated at an office-based laboratory (OBL) between January 2013 and November 2017. A retrospective, single-center study was performed of patients treated at an office-based laboratory (OBL) between January 2013 and November 2017. Key FindingsOf 237 patients with lower extremity arterial occlusive disease, the lesions could not be crossed from an antegrade approach in 39 patients (17%). Of these 39 patients, 14 were then treated using a retrograde distal approach. Although successfully treated, these 14 patients received significantly higher contrast doses with a significantly longer operative time and greater treatment costs compared with those treated by an antegrade approach. Of 237 patients with lower extremity arterial occlusive disease, the lesions could not be crossed from an antegrade approach in 39 patients (17%). Of these 39 patients, 14 were then treated using a retrograde distal approach. Although successfully treated, these 14 patients received significantly higher contrast doses with a significantly longer operative time and greater treatment costs compared with those treated by an antegrade approach. ConclusionsAlthough the operative times, costs, and radiation and contrast dose were greater with retrograde arterial access, it represents a safe and effective method for crossing chronic total occlusions (CTOs) in an OBL. Although the operative times, costs, and radiation and contrast dose were greater with retrograde arterial access, it represents a safe and effective method for crossing chronic total occlusions (CTOs) in an OBL." @default.
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• W4229535703 date "2021-03-01" @default.
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• W4229535703 title "Distal Retrograde Access for Infrainguinal Arterial Chronic Total Occlusions: A Prospective, Single Center, Observational Study in the Office-Based Laboratory Setting" @default.
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• W4229535703 doi "https://doi.org/10.1016/j.jvs.2020.12.007" @default.
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