Retrograde Access for Treating Below-the-Ankle Arterial Disease in CLI

Editor's note: See Dr. Walker's accompanying editorial video. 

Interventional therapy has less morbidity than open surgical procedures and can be effective in cases where there is no surgical option.

The incidence of CLI has increased as diabetes is epidemic worldwide and life expectancy has increased dramatically. Although the foot vessels are often spared direct atherosclerotic involvement (termed pedal sparing in the surgical literature) there are cases where the foot vessels are severely diseased. Patients with severe obstruction of the foot vessels have historically had among the worst prognosis of all patients presenting with CLI.

Retrograde tibial access has clearly improved interventional success rates in patients presenting with CLI. When there is foot vessel involvement this access is typically above the affected foot vessels and not very effective for treating the foot vessels other than to open occlusions above, allowing interventionists to reach the foot vessel occlusions and attempt crossing those.  Pedal loop reconstruction and transcollateral approach have improved the interventional success rates in patients presenting with CLI where foot vessels are involved but are limited by occasional inability to cross some of the totally occluded foot vessels.

 In this issue of Vascular Disease Management, Drs. Palena and Manzi describe the advanced technique of retrograde digital access to increase the success of crossing these totally occluded arteries allowing successful intervention. This approach can be limb saving when no other options exist. I have personally successfully utilized this “extreme” approach in “no other option” patients after hearing the presentations of these authors at the New Cardiovascular Horizon’s meeting in 2013. Digital access is technically challenging but can be accomplished if one follows the recommendations of these authors. This technique should be reserved for patients with CLI who have no other options because these vessels are small and even the placement of microsheaths is often occlusive. Before attempting to utilize this approach, interventionists must clearly know the foot anatomy in detail.

Great strides continue to be made in treating CLI with interventional therapies. Clinicians continuously innovate to improve outcomes. Therapy has evolved to treat more distal arterial disease. These treatments are helping patients to avoid major amputations and the accompanying morbidity and mortality. 

Even with these innovative options, CLI remains a massive worldwide health problem that deserves headline attention as well as innovation, research, and attempts at preventive therapy.