Download this article's Factoid (PDF & PPT for Gold Subscribers)

Peripheral intervention using the more challenging antegrade route results in a higher rate of access site complications including transfusion than does conventional retrograde access, according to a retrospective study published in the April 2011 issue of Archives of Surgery. However, the antegrade approach does not increase the risk of serious events such as death, MI, or stroke.

M. Ashraf Mansour, MD, of Spectrum Health (Grand Rapids, MI), and colleagues reviewed 5,918 cases of peripheral vascular intervention performed at 13 Michigan hospitals between January 2007 and December 2008. The data were obtained from the prospective Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention Quality Improvement Initiative (BMC2PVI) registry. A total of 745 cases (12.6%) were performed via antegrade access.

The most common indication for intervention in both the antegrade and retrograde groups was severe lower extremity claudication (approximately 76%). Other indications included rest pain, limb salvage, and hybrid vascular surgery. Although angioplasty and stenting were the predominant types of intervention, IVUS, lysis, laser, and cryoablation therapies also were performed.

The median procedure time was similar in the 2 groups (80 minutes for antegrade access, 75 minutes for retrograde access), but the number of cases exceeding the median was higher in the antegrade group (54% vs. 49.8% in the retrograde group; P = 0.03). No differences were observed among the types of closure devices used.

Rates of periprocedural mortality, MI, and stroke were similar for both groups. However, blood transfusion, vascular access complications, and subsequent amputation all were more common in the antegrade group (table 1).

Table 1. Periprocedural Complications According to Access Type

The authors note that many of the amputations were planned before intervention. In those cases, treatment was intended to limit the extent of the amputation or improve healing afterward.

Multivariate predictors of vascular access site complications were:

• Female sex (OR 2.10; 95% CI 1.57-2.93; P < 0.001)
• Age greater than 70 years (OR 1.50; 95% CI 1.08-2.01; P = 0.01)
• Larger sheath size (6 Fr: OR 1.60; 95% CI 1.00-2.60; P = 0.047; larger sheaths have higher OR)

Sometimes Antegrade Access Is the Only Option

“In many cases, retrograde access may not be possible for anatomic or technical reasons, such as vessel occlusion or calcification,” the authors observe. “In diabetic patients who present predominantly with infrapopliteal occlusive disease, reaching the target may not be possible from a contralateral approach, leaving [antegrade access] as the only option. Furthermore, in some cases, catheter and wire manipulation is more easily accomplished using [antegrade access].”

In a telephone interview with TCTMD, Dr. Mansour elaborated on situations in which antegrade access may be required. “The more distal the lesion, the more difficult it is to access [with retrograde access],” he noted. “When people have occlusions that are difficult to crack and you need more pushability, antegrade needs to be done. There are also situations where people have a hostile aortic bifurcation, an endograft, . . . or some reason why you can’t come from the opposite side. [Then] you need the antegrade approach.”

“Antegrade access is not always benign,” Dr. Mansour cautioned. To help ensure good outcomes, it is important to select patients carefully and pay attention to anticoagulation and technique, he said. In addition, he recommended that clinicians use ultrasound if they need to guide the puncture, and make sure the puncture is at the right level.

“Also, know that in certain patients complication rates are going to be higher, so be prepared for that,” he counseled.

Study Details

The antegrade access group included fewer women and smokers but more diabetic patients than the retrograde group (all P < 0.001). In addition, the indication for intervention was more frequently rest pain and limb salvage among those in the antegrade vs. the retrograde group.

Vascular complications were defined as a composite of retroperitoneal hematoma, pseudoaneurysm, hematoma requiring transfusion or associated with a decrease in hemoglobin level of at least 3 g/dL, arteriovenous fistula demonstrated by arteriography or ultrasonography, acute thrombosis, or the need for surgical repair of the access site.