Author + information
- Konstantinos Marmagkiolis1,
- Jihad Mustapha2,
- Konstantinos Charitakis3,
- Mehmet Cilingiroglu4,
- Cezar Iliescu5,
- Dmitriy Feldman6 and
- Miguel Montero Baker7
Critical limb ischemia (CLI) affects approximately 2% of patients with peripheral arterial disease (PAD) but it is associated with high cardiovascular and all-cause mortality (25% at 1 year and 41% at 2 years) and amputation rates (25-30% at 1 year). Transpedal access allows the treatment of infrapopliteal disease and it is thought to be safer especially when multiple run-off vessels are patent.
A prospective protocol was developed. We performed a literature search using PubMed from January 2003 to July 2016. Published studies with the following characteristics were included: 1) use of percutaneous transpedal access during endovascular interventions, 2) at least 5 patients examined, 3) manuscript published in English. The type of study, access site characteristics, demographics, target vessel, angiographic results and complications were reviewed.
9 studies (364 patients) were included in our study. The mean patient age was 73.1 years old and 63.6% were male. The most common risk factors were hypertension (87.6%), diabetes mellitus (60.1%), smoking (43.2%), coronary artery disease (CAD) (30.3%) and chronic kidney disease (28.5%). The indication was critical limb ischemia with a Rutherford class 4-6 in 68.7%, severe claudication with Rutherford class 3 in 30.0% and only few with mild claudication or acute limb ischemia. Ultrasound was used to gain access in most cases (63.35%) and fluoroscopy in about 1/3 of all cases (36.35%). The anterior tibial (AT) and pedal artery were the most commonly accessed vessels (56.9%), followed by the posterior tibial (PT) (25.6%) and the peroneal artery (6.7%). Majority of patients (90%) had a chronic total occlusion (CTO) and the average occlusion length was 224.5 ± 54.1 cm. The most common complication was vessel dissection (9.5%), followed by perforation, embolization, hematoma, pseudoaneurysm and AV fistula formation and access site infection.
Transpedal access emerges as an evolving technique for the management of complex lower extremity peripheral arterial disease. The existing data demonstrates its safety and efficacy in the most challenging PAD subgroup of CLI patients with long CTO, run-off disease and previous antegrade technical failure. Larger randomized trials with longer follow-up are needed to establish the long-term safety and efficacy of this technique.