Kronik yüzeyel femoral arter tıkanıklığında retrograd rekanalizasyon: Birincil strateji olarak güvenli ve etkili mi?

Abstract

Amaç: Periferik arter hastalığı (PAH), dünya çapında koroner arter hastalığı ve serebrovasküler olaylardan sonra en sık görülen mortalite ve morbidite nedenlerinden biridir. Kronik tıkalı yüzeyel femoral arter (SFA)’in endovasküler tedavisi (EVT) genellikle antegrad yaklaşımla yönetilir. Retrograd popliteal erişim (RPA), antegrad girişimin başarısız olduğu veya birincil seçenek olarak tercih edildiği durumlarda değerli bir seçenektir. Birinci basamak strateji olarak yüzüstü pozisyonda RPA'nın seçildiği ve rekanalizasyon için perkütanöz kasıtlı ekstralüminal anjiyoplasti (PIER) tekniğinin kullanıldığı hastaları, ileriye doğru girişimin başarısız olduğu ve sırtüstü pozisyonda RPA'nın kullanıldığı hastaları karşılaştırmayı amaçlıyoruz. 15 aylık takip ile rekanalizasyon için çift yönlü “randevous” tekniği kullanıldı. Gereç ve yöntemler: Şubat 2017 ile Nisan 2019 arasında ardışık EVT'leri retrospektif olarak inceledik ve SFA lezyonlarının CTO'sunun rekanalizasyonu için RPA'nın kullanıldığı tüm EVT'leri seçtik. Çalışma, hastaları Grup 1 (n=24) olarak iki gruba ayırdı: Birinci basamak strateji olarak yüzüstü pozisyonda RPA'nın seçildiği ve rekanalizasyon için PIER tekniğinin kullanıldığı hastalar (6F Sheat ile) ve Grup 2 (n= 22): Antegrad girişimin başarısız olduğu ve endolüminal rekanalizasyon ile sırtüstü pozisyonda RPA'nın olduğu veya lezyonu geçerken telin başarısız olduğu hastalar, rekanalizasyon için çift yönlü “çift balon (randevu)” tekniği kullanıldı (Kılıfsız). Bulgular: Teknik başarı oranı %100 oldu. RCC ve ABI her iki grupta da işlem sonrası anlamlı düzeyde iyileşti. Grup 1'de daha fazla hastaya primer stent gerekti (%70,8 vs. %45,4; p<0,05). Grup 2'deki hastaların 9'unda (%40,9) randevöz teknik kullanıldı. Gruplar arasında 30 günlük ve 12 aylık MACE açısından anlamlı fark yoktu. Büyük bir amputasyon, stent kırılması ve ölüm yaşanmadı. 12. ayda amputasyonsuz sağkalım açısından gruplar arasında anlamlı fark bulunmadı (%95,8 vs. %95,4; p>0,05). 1 yıllık uzuv kurtarma oranı her iki grup için de 100 ± 0 idi. Grup 2'de primer açıklık oranları grup 1'e göre daha yüksekti ancak bu fark ancak 6. ayda anlamlı hale geldi (grup 1'de sırasıyla %95,8, %87,5, %79,1'e karşı grup 2'de sırasıyla %100, %95,4, %81,8); p<0,05 yalnızca 6. ay için). Tüm çalışma grubu için 1 yıllık CD-TLR oranı %17,25 idi, grup 1'de daha fazla CD revaskülarizasyon işlemi yapılmış gibi görünüyor ancak anlamlı bir farka ulaşılamadı (%95 Cl %20,8 ila %13,7). Sonuç: RPA tekniğinin kendi avantaj ve dezavantajları vardır. Güvenlik ve etkinlik göz önüne alındığında, ister birincil strateji olarak planlanmış, ister yedek plan olarak ihtiyaç duyulmuş olsun, damar cerrahlarının portföyünde yer almalıdır.

Keywords

• periferik arter hastalığı; kronik total tıkanıklık; retrograd popliteal erişim.

Retrograde recanalization for chronic superficial femoral artery occlusion: is it safe and effective as a primary strategy

Abstract

Aim: Peripheral arterial disease (PAD) is one the most common cause of mortality and morbidity after coronary artery disease and serebrovascular event worldwide. Endovascular treatment (EVT) of chronic occluded superficial femoral artery SFA is generally managed by antegrade approach. Retrograde popliteal access (RPA) is a valuable option when antegrad attempt fails or has also been preferred as a primary choice. We aim to compare patients in whom RPA in prone position was chosen as a first-line strategy and percutaneous intentional extraluminal angioplasty (PIER) technique was used for recanalization, with patients in whom antegrade attempt had failed and RPA in supine position with either endoluminal or bidirectional “randevous” technique was used for recanalization with 15-month follow-up. Material and Methods: We retrospectively studied consecutive EVTs between February 2017 and April 2019, and selected all EVTs in which RPA was used for the recanalization of CTO of SFA lesions were included. The study divided patients into two groups as Group 1 (n=24): patients in whom RPA in the prone position was chosen as a first-line strategy and PIER technique was used for recanalization (with 6F Sheat) and Group 2 (n=22): patients in whom antegrade attempt had failed and RPA in the supine position with endoluminal recanalization or if the wire failed while crossing the lesion, a bidirectional “double-balloon (rendezvous)” technique was used for recanalization (Sheatless). Results: Technical success rate was %100. RCC and ABI were improved post procedurally in both groups significantly. Primary stenting was required in more patients in group 1(70.8% vs. 45.4%; p<0.05). In group 2, randevous technique was used in 9 patients (40.9%). There was not any significant difference between the groups in terms of 30-day, and 12-month MACE. There were no major amputations, stent fracture, and death. In the 12th month, no significant differences was found between the groups for amputation-free survival (95.8% vs. 95.4%; p>0.05) .1-year limb-salvage rate was 100 ± 0 for both groups. Primary patency rates of group 2 were higher than group 1, but this difference became significant only at 6th month (95,8%, 87.5%, 79.1% for group 1vs. 100%, 95.4%, 81.8% for group 2, respectively; p<0.05 only for 6th month). The 1-year CD-TLR rate was 17,25% for whole study group, group 1 seems to have more CD-revascularization procedures but it did not reach to a significant difference (95% Cl 20.8% to 13.7%). Conclusion: The RPA techniques has their own advantage and disadvantages. Considering safety and effectiveness, either planned as a primary strategy or needed as a back-up plan, it should be in the portfolio of vascular surgeons.

Keywords

• peripheral arterial disease
• chronic total occlusion
• retrograde popliteal access.

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