Feasibility and safety of transpedal endovascular intervention in patients with single infrapopliteal run off

Htun, Wah Wah

Background
With maturing in endovascular technology and further development in new devices, endovascular therapy (EVT) has been a preferred treatment for patients with peripheral arterial disease (PAD). Tibio-pedal approach (TPA) has been utilized for more than a decade for EVT. However, the safety of TPA in single runoff vessel has not been fully addressed.

Methods
This is a retrospectively analysis of 250 consecutive peripheral interventions in 187 patients from Jan 1^st 2015 to May 31^st, 2018 in a single outpatient ambulatory laboratory. All patients underwent EVT using primary retrograde TPA via single tibial runoff vessel. They are prospectively monitored till October 30^th, 2018. Demographic data, procedural success rate, peri procedural major adverse complications and 30 days outcomes were recorded.

Results
In this study, there was 45% male and average age was 78 years. Renal dysfunction (CKD stage 3 and above) was seen in 67%, hypertension in 91%, diabetes in 50%. 62% presented with chronic limb ischemia (Rutherford class 4 and above) and 8% had foot ulcer. Dorsal pedis artery was the most common TPA site (51%) followed by peroneal artery (34%), and posterior tibial artery(15%). Dual access using mainly left radial artery was needed in 44%. In 82% of patients, there was significant femoropopliteal disease in addition to infrapopliteal disease. Most patients (99.6%) underwent successful balloon angioplasty and only 0.4% underwent stent in SFA. Mean amount of contrast use was 43 cc (18-60cc). Mean fluoroscopy time is 16 minutes (1- 62 min). Mean radiation dose was 89 mGy (14 to 2739 mGy). Modified patent hemostasis was used in all patients. No patients had significant access site bleeding, hematoma, worsening kidney dysfunction or acute limb ischemia following index procedures. There was no amputation or deaths in our mid-term follow up.

Conclusions
Our study demonstrates that TPA for single tibial runoff vessel is feasible and safe in experienced hands for treatment of disabling PAD. Given its better safety profile compared to transfemoral access, we should not shy away from using TPA in patients with single infrapopliteal runoff vessel.