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Many adequate access options for procedures on tibial arteries
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LAS VEGAS — Many different access sites have been used successfully for endovascular procedures on tibial arteries in patients with critical limb ischemia, an expert said at VIVA 16.
“Any access site is fair game as long as the outcome is revascularization of the tibial artery,” Jihad A. Mustapha, MD, FACC, FSCAI, director of cardiovascular catheterization laboratories at Metro Health Hospital in Wyoming, Michigan, said during a presentation.
The goals are to place a sheath in a location that allows the operator to access the appropriate part of the tibial artery, to choose a proper treatment strategy based on the access site and to find an exit strategy, which preferably should be determined before entrance to the artery, Mustapha said.
This is crucial because mortality rates of patients with critical limb ischemia are high — estimated at 4.2% to 10.4% during the perioperative period, 9.1% to 33% at 1 year, and 25.6% to 81.5% at 5 years — so “a good result with tibial access gives you a mortality benefit,” he said.
Many trials for below-the-knee interventions prohibit retrograde access, but this is not warranted, according to Mustapha. It impedes enrollment and promotes antegrade access, which is associated with a higher rate of dissection, especially in lesions with chronic total occlusion.
Many patients with CLI have comorbidities such as diabetes and hypertension that make access challenging, and those with Rutherford class 4 or 5 often have anatomies that make access difficult, he said.
Investigators from the PRIME registry performed an analysis of access-site choices for procedures on 407 patients in that cohort, and found all access options were associated with a low rate of complications, according to Mustapha, who shared findings that were published in the Journal of Invasive Cardiology.
For 896 access sites from 649 procedures, the researchers assessed access success, immediate outcomes, complications and length of hospital stay.
Common femoral retrograde access was used 34.6% of the time, common femoral antegrade access 33%, posterior tibial access 12.1% and anterior tibial access 12.1%. The remainder consisted of other options.
Mean number of attempts was 1.2 for common femoral retrograde access, 1.2 for common femoral antegrade access, 1.5 for posterior tibial access and 1.4 for anterior tibial access, Mustapha said.
Of the four main access choices, anterior tibial access had the longest mean time to access at 59 seconds, with the others being 45 seconds or less.
Success rates were 99.4% for common femoral retrograde access, 97.3% for common femoral antegrade access, 90.7% for posterior tibial access and 92.6% for anterior tibial access, he said.
Complication rates were very low across all access sites, he said, noting there were no access-site related cases of death, thrombosis, aneurysm or compartment syndrome.
There were no differences between antegrade and retrograde access in fluoroscopy time (antegrade, 22 minutes; retrograde, 25 minutes) or length of stay (antegrade, 1.5 days; retrograde, 1.3 days), but antegrade access was associated with less contrast use (163 cc vs. 196 cc; P < .001), Mustapha said.
“We need to adjust to accommodate the new age,” he said. “Tibial access is safe and can be very effective, as well.” – by Erik Swain
References:
Mustapha JA. Techniques. Presented at: VIVA 16; Sept. 18-22, 2016; Las Vegas.
Mustapha JA, et al. J Invasive Cardiol. 2016;28:259-264.
Disclosure: Mustapha reports financial relationships with Abbott Vascular, AccessClosure, Bard Peripheral Vascular/Lutonix, Biotronix, Boston Scientific, Cardiovascular Systems Inc., Cook Medical, Cordis, Intact Vascular, Medtronic, Spectranetics, Terumo Medical and TriReme.