Endovascular treatment of critical limb ischemia are some of the most technically complex and challenging procedures. In the last decade there has been significant advances in technical skills allowing treatment of patients that previously would have had no options for limb salvage.
These procedures are often time consuming taking 2-4 hours to complete. To minimize procedure time, contrast use, and radiation exposure, an antegrade ("downhill") approach offers significant advantages versus a retrograde ("up and over") approach. Additionally, an antegrade approach gives the operator increased catheter and wire control because of the direct downhill approach. A retrograde approach reduces mechanical advantage and control over catheters and guidewires. In patients with no stenosis in the iliac, common femoral and proximal superficial femoral arteries an antegrade approach should be used.
Historically, an antegrade approach was performed using the common femoral artery (CFA). This approach is often difficult, particularly in obese patients where the stomach (pannus) makes gaining access to the CFA difficult. Additionally antegrade CFA punctures have higher complication rates compared to retrograde CFA punctures.
For the last several years I have been doing the majority of my CLI procedures using an superficial femoral artery (SFA) antegrade approach and I have one of the largest experiences in the USA. This approach eliminates the disadvantages of using the CFA. SFA access is extremely safe and has a very low complication rate and yet adoption by other proceduralists has been slow - old traditions are hard to change.
I analyzed the last 150 antegrade SFA procedures that I have done. All procedures were for patients with CLI and were done under ultrasound guidance. 6 or 7 French sheaths were placed. All sites were closed with a 6F Angioseal device. No patient had significant bleeding, arterial occlusion or other complication requiring open surgery or hospital transfer. 7 (4.6%) patients developed a post procedure pseudo aneurysm. All were managed with ultrasound guided thrombin injection. There we no arterial venous fistula. 12 (8%) had a "large" hematoma documented. None of these patients required any intervention. 4 patients had acute occlusion of the SFA after deployment of the Angioseal device. All of these patients were successfully treated with a second endovascular procedure using angioplasty or angioplasty and stenting. There were no instances of retroperitoneal hemorrhage (which can occur with CFA access), compartment syndrome or branch artery injury or arterial dissection.
Antegrade superficial femoral artery access is safe and offers significant advantages or traditional common femoral artery access.
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