Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 151-155

Antegrade access for peripheral vascular disease intervention of the lower limb – Our experience at a tertiary center


Department of Vascular and Endovascular Surgery, Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Submission01-Nov-2021
Date of Acceptance22-Jan-2022
Date of Web Publication13-Jun-2022

Correspondence Address:
Nivedita Mitta
Department of Vascular and Endovascular Surgery, Ramaiah Medical College, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_117_21

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  Abstract 


Purpose: Antegrade superficial femoral artery (SFA) access for peripheral artery disease reduces the time, radiation, and contrast required as compared with contralateral common femoral access (CFA). However, this technique remains underutilized and understudied in the treatment of SFA, popliteal and tibial disease, and there remains limited data on the safety and efficacy of antegrade SFA access. Materials and Methods: An observational review of lower extremity peripheral arterial interventions was conducted from January 2014 to July 2021. Interventions necessitating CFA access such as iliac, common femoral, or deep femoral artery revascularization were excluded. In addition, interventions potentially requiring large sheaths were excluded. Relevant demographic and treatment variables including postoperative complications were abstracted. Results: We identified 482 patients, who underwent revascularization of the SFA, popliteal and tibial arteries. Antegrade SFA access was chosen in all these patients. Access was attained either through ultrasound or fluoroscopy guidance in 94.6% of patients. The overall rate of complications was low (access site complications, hematoma, pseudoaneurysm, etc.). Conclusions: Percutaneous antegrade SFA access can be performed safely and remains an effective alternative to retrograde CFA access with significantly less complications and is also associated with lesser utilization of fluoroscopy and contrast.

Keywords: Access, antegrade puncture, femoral access


How to cite this article:
Basavanthappa RP, Mitta N, Ramswamy CA, Desai SC, Chowdary R H, Kunapareddy H, Vishnumolakala VK. Antegrade access for peripheral vascular disease intervention of the lower limb – Our experience at a tertiary center. Indian J Vasc Endovasc Surg 2022;9:151-5

How to cite this URL:
Basavanthappa RP, Mitta N, Ramswamy CA, Desai SC, Chowdary R H, Kunapareddy H, Vishnumolakala VK. Antegrade access for peripheral vascular disease intervention of the lower limb – Our experience at a tertiary center. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Jul 3];9:151-5. Available from: https://www.indjvascsurg.org/text.asp?2022/9/2/151/347250




  Introduction Top


Retrograde access is obtained through puncture of contralateral common femoral artery access (CFA). Ipsilateral antegrade access is an alternative approach to the traditional retrograde attempt. The mode of access as antegrade was favored in patients with a hostile contralateral groin, difficult inflow anatomy, patient habitus, etc. However, we present antegrade access as the primary choice for ipsilateral endovascular interventions. The factor which was a deterrent for many to accept this technique was the documented higher incidence of access point complications. We sought out to evaluate the same and find that the rate of complications is the same as in contralateral approach, if not lesser.

Aim of the study

The aim of this study was to study this “under-studied” technique and at the same time to assess the safety and efficacy of the technique. We realized that although an antegrade access of the femoral artery was gaining popularity and is now considered, by many, to be the mainstay of gaining access for tackling lesions of the distal superficial femoral artery (SFA) and below the knee lesions, there has not been a lot of research into the intricacies of the technique. We look into the same and to analyze the factors such as radiation used, contrast utilised and the time taken for the same. We also attempt at weighing in the merits and demerits of the technique.


  Materials and Methods Top


All the data were collected as part of an observational review from patient records, operative records, and intraoperative findings. The study period was from January 2014 to July 2021 and constituted 482 patients. The inclusion criteria were patients with a preoperative angiogram and Doppler evaluation and those with unilateral, infrainguinal disease (SFA, popliteal, infrapopliteal, and multisegmental disease). Patients who had had a previous intervention were excluded. Hence, also were patients with ipsilateral suprainguinal disease and those with proximal SFA and CFA disease. The data were analyzed using the statistical analysis (student t-test and Chi-square testing, wherever applicable) and P value was calculated to assess significance. Our data of antegrade access were compared with data from two studies, i.e., Pezold et al. and Blumberg et al. Once established that both datasets were comparable using the goodness to fit test, we went on to compare our antegrade access data with their contralateral retrograde access data using Student t-test and calculating P value from there on. This was done as we did not have a comparison group as we, as a protocol, do not do a retrograde contralateral puncture for lesion of the SFA and infrapopliteal segments.


  Results Top


The basic demographic data collected is shown in [Table 1]. The average age of presentation was 76.2 ± 10.6 years with males constituting more than 60% of our data set. The average body mass index (BMI) was 26.3 ± 4.1 with the highest BMI being 34.3. Of the associated comorbidities, almost two thirds of our patients had diabetes and hypertension and about half of them were on Aspirin in the preoperative period.
Table 1: Demographic data of patients included

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The comparison of our antegrade data with that from the review of literature is as shown in [Table 2]. The same was subject to the statistical analysis to assess comparability of both datasets [Table 3]. We found that procedure details such as access time, total contrast used and radiation exposure per procedure were comparable. The distribution pattern of disease segments was also comparable in terms of multilevel disease constituting about 50% of cases and infrapopliteal cases constituting a quarter of the cases. In terms of complications, we found that our rate of complications in the antegrade access was much lower than both study groups. However, the rate of pseudoaneurysm, distal embolization, and dissection was comparable with the data from Pezold et al. We only had five incidents of hematoma formation, all of which were minor and did not require any intervention apart from compression for an extended period of time.
Table 2: Comparison of antegrade access group with dataset from review of literature

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Table 3: Comparison of antegrade access group with dataset of retrograde contralateral access from review of literature

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As described, once the comparability was established, we carried out statistical analysis to compare our data with that of both groups. We found that the access time in our data was a quarter of that seen in the contralateral retrograde group. Furthermore, the contrast used was about half and so was the total radiation exposure. All these factors were statistically significant. Our distribution of the disease segments was similar but not of statistical significance. In terms of complications, we found that our rates of complications were significantly lower than the data groups studied. However, the important point here is the observation that in the Pezold et al.[1] group, complications in both forms of access were comparable but in the Blumberg et al.[2] group, the rate of complications in the retrograde contralateral was significantly higher than the ones in the antegrade access group. More so, in terms of hematoma at the access site which was roughly three times more with the antegrade approach.

In addition to the statistical analysis, we find that the amount of hardware used for the antegrade access route was half that required for the retrograde contralateral access approach. This significantly brought down the costs of the antegrade technique and adding up costs of the individual hardware used, we arrive at the conclusion that the costs were 3.5–4 times lower [Figure 1].
Figure 1: Pictoral depiction of material needed and costs incurred in both types of access

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Another keen observation was that the surgeon's ease of doing the procedure was better with the anterior access method. There was no quantitative assessment of this but there was reporting of better control, manoeuvrability, torquability, steering, pushability, support and tactile feel in the antegrade approach by all three consultant vascular surgeons who participated in the study.


  Discussion Top


Peripheral angioplasty continues to be the first-line intervention for most vascular patients with peripheral vascular disease. The complications of a percutaneous approach are well documented. For the practicing interventionalist undertaking this procedure, the choice is always between ipsilateral ante-grade approach, which facilitates better wire control, versus contralateral retrograde approach, which has the advantage of being a technically easier puncture and with favorable orientation for SFA selection.[3]

There are four reasons contralateral retrograde access is favored for lower extremity arterial endovascular interventions as compared to antegrade access.[3]

  1. Imaging of the aortoiliac arteries to rule out occlusive disease is possible
  2. Considered technically easier to perform
  3. Considered to have a favorable orientation for SFA selection
  4. Bleeding complications and the need for emergent femoral artery repair were considered lower with contralateral retrograde access.


A previous study[4] comparing both techniques found that anterior access is more likely to result in periprocedural complications than the retrograde access.

With antegrade puncture, selection of the SFA can be difficult and combined with the associated risk of high (or low) puncture, it may seem an unattractive initial approach for many. In this article, we have demonstrated that ante-grade access is associated with higher technical success and reduced contrast (contrast-induced nephropathy) and radiation doses with significant difference in complications compared to documented complications of retrograde contralateral puncture.[3]

It is understood that to rule out proximal aortoiliac occlusive disease, a computed tomography angiography has to be obtained, which requires more contrast and radiation than an aortoiliac arteriogram or rely on noninvasive studies. From a technical stand point, it is impossible to perform antegrade puncture in very obese patients, even after taping the pannus proximally.[4] It was also noted that manual pressure for 4F sheaths and closure devices for 6F sheaths were utilised.[4]

Ramirez et al.[5] in a nationally representative sample found that closure devices placed outside instructions for use for anterior access were safe and associated with lower odds of hematoma. It was further stated that closure devices for anterior access may improve outcomes with a potential to decrease health-care utilization associated with sheath removal.[4]

Conventionally, arterial access is made into the common femoral artery (CFA) by palpation. With the better availability of ultrasound (US) in angiography suites, the use of US-guided arterial access is becoming more popular.[6]

During the antegrade approach to the CFA, a common problem is the soft-tissue layer over the artery, especially in obese patients. Other problems are steering the guide wire into the SFA or the accidental puncture of the deep femoral artery. These problems can be time-consuming and lead to repeated punctures, hematomas, and aneurysms in the groin.[7] Antegrade access is especially difficult if a stenosis in the CFA is present.

The most common complications after percutaneous vascular interventions are access site complications.[8] Although reintervention is not typically required, subsequent treatment and procedures can increase the patient's morbidity.[8] Access site complications include hematoma in varying degrees of severity and access site stenosis or occlusion. Groin hematomas after access can be treated expectantly with transfusion only, with thrombin injection if a pseudoaneurysm is present, and with operative intervention by either open surgical or endovascular technique.[9],[10] Surgical exploration is usually reserved for cases involving hemodynamic instability, persistent anemia despite transfusions, skin compromise, distal ischemia, neuropathy, or severe pain. Access site stenosis or occlusion is a known complication of catheter-based interventions. Compression after sheath removal can lead to thrombosis or narrowing.

Access failure and complications significantly decreased with experience of the operator during the time of the study.[7],[10] This reflects our study's multivariable analysis as the OR for any hematoma or hematoma requiring intervention decreased over time. One single-center retrospective review of 1371 percutaneous revascularizations showed a 5% access site complication rate.[11] Independent predictors of access site complications included age, Congestive heart failure (CHF), and preoperative anticoagulation. A review of percutaneous access for percutaneous coronary intervention in a regional registry showed an access site complication rate of 2.98%. 19 Risk factors identified included age, female sex, lower body surface area, CHF, chronic obstructive pulmonary disease, renal failure, peripheral vascular disease, bleeding disorder, emergent cases, myocardial infarction, and shock. Findings from both of these studies were consistent with predictors for access site complications that we found in our analysis. Multivariable analysis of access site stenosis or occlusion was not performed in our study because of low numbers, although there was no difference in the matched data.

The biggest merit of our study was that it was a single centre data set. Hence, all procedures were done with similar protocols in place under the same circumstances. There are three senior consultants at out center and all decisions about intervention and procedures were made with a consensus. Like all studies, our study had some shortcomings as well. All patients needed a preoperative computed tomography or magnetic resonance angiogram which added to the amount of radiation and contrast needed eventually. We did not have a comparison group of contralateral retrograde puncture patients as described earlier and hence had to rely on comparison groups from elsewhere. Finally, there was no way of objectively stratify in patients based on the closure compression method.


  Conclusions Top


Percutaneous antegrade SFA access can be performed safely and remains an effective alternative to retrograde CFA access with significantly less complications and also statistically significantly less utilization of fluoroscopy and contrast. Although it is often perceived to be more difficult and does require experience, this approach remains a viable alternative to retrograde contralateral approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pezold M, Berland T, Rockman C, Sadek M, Jacobowitz G, Cayne N, et al. Antegrade superficial femoral access for lower extremity arterial disease is a safe and effective technique. J Vasc Surg 2019;70:e27-8.  Back to cited text no. 1
    
2.
Blumberg SN, Sadek M, Maldonado T, Jacobowitz G, Gelbfish G, Cayne N, et al. Safety and effectiveness of antegrade superficial femoral artery access in an office-based ambulatory setting. J Vasc Surg 2017;65:176S-7S.  Back to cited text no. 2
    
3.
Cragg J, Lowry D, Hopkins J, Parker D, Kay M, Duddy M. Safety and outcomes of ipsilateral antegrade angioplasty for femoropopliteal disease. J Vasc Surg 2018;67:1629.  Back to cited text no. 3
    
4.
Danetz JS, McLafferty RB, Schmittling ZC, Lee CH, Ayerdi J, Markwell SJ, et al. Predictors of complications after a prospective evaluation of diagnostic and therapeutic endovascular procedures. J Vasc Surg 2004;40:1142-8.  Back to cited text no. 4
    
5.
Ramirez JL, Zarkowsky DS, Sorrentino TA, Hicks CW, Vartanian SM, Gasper WJ, et al. Antegrade common femoral artery closure device use is associated with decreased complications. J Vasc Surg 2020;72:1610-7.e1.  Back to cited text no. 5
    
6.
Gutzeit A, Schoch E, Sautter T, Jenelten R, Graf N, Binkert CA. Antegrade access to the superficial femoral artery with ultrasound guidance: Feasibility and safety. J Vasc Interv Radiol 2010;21:1495-500.  Back to cited text no. 6
    
7.
Nice C, Timmons G, Bartholemew P, Uberoi R. Retrograde vs. antegrade puncture for infra-inguinal angioplasty. Cardiovasc Intervent Radiol 2003;26:370-4.  Back to cited text no. 7
    
8.
Siracuse JJ, Farber A, Cheng TW, Raulli SJ, Jones DW, Kalish JA, et al. Common femoral artery antegrade and retrograde approaches have similar access site complications. J Vasc Surg 2019;69:1160-6.e2.  Back to cited text no. 8
    
9.
Tisi PV, Callam MJ. Treatment for femoral pseudoaneurysms. Cochrane Database Syst Rev 2013;CD004981. DOI: 10.1002/14651858.CD004981.pub4.  Back to cited text no. 9
    
10.
Calligaro KD, Balraj P, Moudgill N, Rao A, Dougherty MJ, Eisenberg J. Results of polytetrafluoroethylene-covered nitinol stents crossing the inguinal ligament. J Vasc Surg 2013;57:421-6.  Back to cited text no. 10
    
11.
Biondi-Zoccai GG, Agostoni P, Sangiorgi G, Dalla Paola L, Armano F, Nicolini S, et al. Mastering the antegrade femoral artery access in patients with symptomatic lower limb ischemia: Learning curve, complications, and technical tips and tricks. Catheter Cardiovasc Interv 2006;68:835-42.  Back to cited text no. 11
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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