Retrospective Analysis of Major Adverse Outcomes of Retrograde Access Revascularization Patients

Lower extremity endovascular revascularizations in patients with peripheral artery disease primarily utilize contralateral femoral artery access. However, retrograde access from a tibial and/or pedal vessel is increasingly used as an access point to facilitate crossing a lesion. This study aims to compare outcomes between antegrade access and retrograde access patients to determine if retrograde access is associated with greater risk of negative outcomes. This retrospective analysis included 577 endovascular atherectomies from two institutions from 2014 to 2022. Retrograde access patients were defined as patients who underwent endovascular access from the anterior tibial, posterior tibial, peroneal, or dorsalis pedis artery. Major adverse limb event (MALE) was defined as open arterial bypass surgery, minor amputation, or major amputation. Multivariate logistic regression models calculated the odds ratio of MALE and controlled for demographics and comorbidities. Cox proportional hazard analysis was performed to analyze time-to-event data and controlled for demographics and comorbidities. Among the 577 endovascular revascularizations, 63 (10.9%) were retrograde access revascularizations, 44 of which were successful crossing lesions via a retrograde approach. Patients requiring retrograde access were more likely to have a previous history of surgical interventions (35.4% vs 68.8%; P < .001) and a lower average number of preoperative patent tibial run-off vessels (1.75 vs 1.05; P < .001). In this analysis, patients undergoing retrograde access were not at greater risk of access site complications defined as hematomas, access site thrombosis, infection, or pseudoaneurysm (6.4% vs 2.1%, P = .34). On multivariate logistic regression, retrograde patients were not at higher odds of MALE (odds ratio, 1.61; 95% confidence interval, 0.61-4.73; P = .36). Cox proportional hazard analysis showed that retrograde patients did not have a greater hazard ratio for MALE (HR, 0.94; 95% confidence interval, 0.41-2.12; P = .88) (Figure). Despite worse preoperative conditions, retrograde access patients were not at greater risk of MALE or access site complications compared with antegrade access patients. The lack of difference in longitudinal outcomes, albeit with a smaller retrograde access cohort, indicates that retrograde access is as safe and effective as antegrade access for patients whose occlusions cannot be crossed from the antegrade direction.