The clinical utility of below-the-ankle angioplasty using "transmetatarsal artery access" in complex cases of CLI

Abstract

Objectives: To appraise clinical results of foot arteries recanalization using percutaneous retrograde transmetatarsal arteries access followed by retrograde recanalization of foot and tibial vessels.

Background: Arterial revascularization by means of percutaneous transluminal angioplasty (PTA) is a mainstay in the management of patients with critical limb ischemia (CLI). Nonetheless, when employing standard approaches, success rate remain suboptimal. We report the clinical results of foot arteries recanalization through transmetatarsal artery access.

Methods: From September 2011 to November 2012, 38 patients (28 men; mean age 73.2 ± 11.4 years) underwent transmetatarsal artery access after antegrade recanalization failure, followed by retrograde recanalization of the foot and tibial vessels. The primary end point was TcPO₂ improvement. The secondary end point was limb salvage rate, amputation-free survival rate and radiation exposure.

Results: Technical success (ability to deliver the balloon across the lesion and inflate it at nominal pressure) was achieved in 33 (86.84%) of cases, with <50% residual stenosis and no complications. Failures were because of spasm or no true lumen re-entry. During follow-up (mean 6.7 ± 2.3 months/range 1-14) clinical improvement was observed in the patients having technical success, with TcPO₂ increasing, from 10.3 ± 7.6 to 50.7 ± 8.2 mm Hg, avoiding major amputations. Amputation-free survival rate calculated by Kaplan-Meier analysis was 81.5% at 12 months. Radiation exposition was major than in patients treated by antegrade way (45.5 ± 56.1 vs. 52.5 ± 11.5 min of fluoroscopy and 69.1 ± 83.2 vs. 94 ± 26.5 Gym(2) of X-ray dose; P < 0.001).

Conclusion: Transmetatarsal artery access appears feasible and beneficial in cases with a failed antegrade recanalization and unsuitable for retrograde pedal/plantar access.

Keywords: critical limb ischemia; infrapopliteal occlusions; limb salvage; retrograde recanalization.