Short-Term Outcomes After Retrograde Versus Antegrade Crossing Approaches for Femoropopliteal Occlusive Disease: An Interview With Shirling Tsai, MD

JIC catches up with Dr Shirling Tsai about her Editor's 2023 Top 10 article, "Short-Term Outcomes After Retrograde Versus Antegrade Crossing Approaches for Femoropopliteal Occlusive Disease." Read the article here.

Transcript:

Hi, I'm Dr Shirling Tsai. I'm a vascular surgeon at the Dallas VA And at UT Southwestern, and I'm going to talk briefly about our paper, Short-Term Outcomes After Retrograde Versus Antegrade Crossing Approaches for Femoropopliteal Occlusive Disease.

0:25: What inspired your group to initiate this study?

This is a paper I wrote with a resident who became one of our fellows a couple of years ago, and we use the XLPAD registry, which is a multi-center retrospective registry of patients undergoing infrainguinal endovascular procedures, and we thought it would be interesting to look at antegrade vs retrograde crossing approaches to mostly SFA popliteal disease. As a vascular surgeon, we thought this was interesting just because, really, I was interested in seeing if people did better with retrograde approach and if there were more complications from the pedal access. We always thought that people would do better, and maybe the limb salvage would be better, because the endpoint of the crossing might be more…we might not propagate a dissection so much if we went retrograde, but there was never really good data to show that. So, we thought we would use this registry, the XLPAD registry, which has a lot of granular data about procedures and outcomes and see if we could sort of dig into this and figure some stuff out.

1:45: Did any of the results of the study surprise you? Was there anything that particularly stood out about what you found?

You know, it wasn't actually really surprising. We had always thought, you know, we didn't find many differences in terms of major outcomes. We did find a difference in amputation rate at a year, and this was consistent with our hypothesis that maybe with the retrograde approach we would not propagate a dissection so far distally as we would from an antegrade approach. In practice, you know, this paper started several years ago, and it just took us a while to do the analysis and write it. In practice, I think a lot of people use the retrograde approach more often now, and probably start right off the bat with a retrograde approach. But at the time we were working on this project and the analysis it was still relatively novel, and it was a good thing, I think, to compare the 2 approaches. We matched our patients one-to-one. So, you know, in previous studies, we couldn't match them so well, or you know, with propensity matching, you don't get as good matching, but we actually combed through all of our patients and matched them one-to-one based on a lot of criteria that we've mentioned in the paper. And so, I think it's a pretty well-matched group to look at procedural details and sort of mid- and short-term outcomes after the 2 approaches.

3:07: To your knowledge has anything evolved in this space since your study was completed? Is there anything you'd like to study further based on the results of this study?

Yeah, I think, the retrograde approach, or like the bi-directional approach, is used a lot more now. And I mean, almost always these days, if you see somebody with a SFA occlusion, you know, you always think oh, we should probably prep the foot, just in case and this is really mainstream in practice now, I think. So, I think the practice has evolved a fair amount. I think one thing that you know, this paper didn't get a chance to look at, and we don't really see a lot of is the pedal access complications. You know, this is something we always worry about when you stick these small pedal vessels. And I don't think the complication rate is very well documented, you know. In terms of gut feeling we try not to stick the main runoff vessel, and if somebody has single vessel runoff, we really try, you know, we're really a little hesitant to use pedal access. But that's one thing that I think we could look into more. It's hard to look into that in bigger registries like the SVS VQI, for example - we just don't get so much procedural detail in that. The nice thing about the XLPAD database, or actually institutional-based databases, is that you can dig through the chart and get those little details about the procedure that I think can sort of shed more light and sort of add to the literature a little more.

4:35: What can we look forward to seeing next from your group?

We have a couple of things going on. We, you know, we are always trying to add to the XLPAD database, that registry. We have a recent paper looking at sort of SFA occlusions in general, and then sort of offshoots of that looking at SFA occlusions and patients with renal disease. We have one recent abstract looking at heart failure, the impact of heart failure or low EF on outcomes. So, all sorts of things looking at outcomes after infrainguinal interventions.