Abstract：
OBJECTIVE: To investigate dissection severity, need for bailout stenting and limb outcomes in patients undergoing antegrade vs. retrograde revascularisation.
METHODS: Consecutive patients who underwent either antegrade or retrograde revascularisation after failed antegrade recanalisation of long femoropopliteal chronic total occlusion (CTO) due to symptomatic peripheral artery disease between January 2017 and June 2022 were studied. Retrospective case control matching was used to adjust for lesion length and calcification using the peripheral artery calcification scoring system (PACSS). Procedural outcomes included severity of dissection (Type A to F dissections, numerically graded on a scale from 0 - 6 with increasing severity) after angioplasty and number and location of stents needed to be implanted during the index procedure. Additionally, clinically driven target lesion revascularisation (CD-TLR) and major (above ankle) amputation rates were assessed during follow up.
RESULTS: A total of 180 patients were analysed who underwent antegrade (n = 90) or retrograde after failed antegrade (n = 90) recanalisation. The median patient age was 76.0 (interquartile range [IQR] 67.0, 82.0) years and 76 (42.2%) were female. Moreover, 78 patients (43.3%) had intermittent claudication, whereas 102 (56.7%) had chronic limb threatening ischaemia (CLTI). The mean lesion length was 30.0 (IQR 24.0, 36.0) cm with moderate to severe (3.0 [IQR 2.0, 4.0]) lesion calcification. Dissection severity after angioplasty was higher in the antegrade than retrograde after failed antegrade recanalisation group (4.0 [IQR 3.0, 4.0] vs. 3.0 [IQR 2.0, 4.0]; p < .001). Additionally, the number of stents in all segments and the rate of bailout stenting in popliteal segments was significantly higher with the antegrade strategy (2.0 [IQR 1.0, 3.0] vs. 1.0 [IQR 0, 2.0], p < .010; and 37% vs. 14%, p < .001). During a median follow up of 1.48 (IQR 0.63, 3.09) years, CD-TLR rates (p = .90) and amputation rates in patients with CLTI (p = .15) were not statistically significant.
CONCLUSIONS: In complex femoropopliteal CTOs, retrograde after failed antegrade recanalisation, is safe for endovascular revascularisation, which in experienced hands may result in less severe dissections and lower rates of stent placement. However, considering the relatively short follow up, CD-TLR and amputation rates were not statistically different between the two approaches. [German Clinical Trials Register: DRKS00015277.].
METHODS: Consecutive patients who underwent either antegrade or retrograde revascularisation after failed antegrade recanalisation of long femoropopliteal chronic total occlusion (CTO) due to symptomatic peripheral artery disease between January 2017 and June 2022 were studied. Retrospective case control matching was used to adjust for lesion length and calcification using the peripheral artery calcification scoring system (PACSS). Procedural outcomes included severity of dissection (Type A to F dissections, numerically graded on a scale from 0 - 6 with increasing severity) after angioplasty and number and location of stents needed to be implanted during the index procedure. Additionally, clinically driven target lesion revascularisation (CD-TLR) and major (above ankle) amputation rates were assessed during follow up.
RESULTS: A total of 180 patients were analysed who underwent antegrade (n = 90) or retrograde after failed antegrade (n = 90) recanalisation. The median patient age was 76.0 (interquartile range [IQR] 67.0, 82.0) years and 76 (42.2%) were female. Moreover, 78 patients (43.3%) had intermittent claudication, whereas 102 (56.7%) had chronic limb threatening ischaemia (CLTI). The mean lesion length was 30.0 (IQR 24.0, 36.0) cm with moderate to severe (3.0 [IQR 2.0, 4.0]) lesion calcification. Dissection severity after angioplasty was higher in the antegrade than retrograde after failed antegrade recanalisation group (4.0 [IQR 3.0, 4.0] vs. 3.0 [IQR 2.0, 4.0]; p < .001). Additionally, the number of stents in all segments and the rate of bailout stenting in popliteal segments was significantly higher with the antegrade strategy (2.0 [IQR 1.0, 3.0] vs. 1.0 [IQR 0, 2.0], p < .010; and 37% vs. 14%, p < .001). During a median follow up of 1.48 (IQR 0.63, 3.09) years, CD-TLR rates (p = .90) and amputation rates in patients with CLTI (p = .15) were not statistically significant.
CONCLUSIONS: In complex femoropopliteal CTOs, retrograde after failed antegrade recanalisation, is safe for endovascular revascularisation, which in experienced hands may result in less severe dissections and lower rates of stent placement. However, considering the relatively short follow up, CD-TLR and amputation rates were not statistically different between the two approaches. [German Clinical Trials Register: DRKS00015277.].
摘要：
目的：调查夹层严重程度，顺行患者对救助支架置入和肢体结局的需求与逆行血管再生。
方法：顺行与顺行的连续患者研究了2017年1月至2022年6月间因有症状的外周动脉疾病导致股pop动脉长期慢性完全闭塞(CTO)顺行再通术失败后的逆行血运重建.回顾性病例对照匹配用于使用外周动脉钙化评分系统（PACSS）调整病变长度和钙化。程序性结果包括夹层的严重程度(A型至F型夹层，在血管成形术后，数字分级为0-6，严重程度不断增加），并且在索引手术过程中需要植入支架的数量和位置。此外,随访期间评估了临床驱动的靶病变血运重建(CD-TLR)和主要(踝关节以上)截肢率.
结果：共分析了180例顺行（n=90）与顺行顺行失败后逆行（n=90）。中位患者年龄为76.0岁（四分位距[IQR]67.0，82.0岁），女性为76岁（42.2％）。此外，78例患者（43.3%）有间歇性跛行，而102例（56.7%）表现为慢性威胁肢体缺血（CLTI）。平均病变长度为30.0（IQR24.0，36.0）cm，中度至重度（3.0[IQR2.0，4.0]）病变钙化。血管成形术后的解剖严重程度高于顺行。顺行再通失败后的逆行(4.0[IQR3.0，4.0]与3.0[IQR2.0,4.0]；p<.001)。此外,在顺行策略下，所有节段的支架数量和pop节段的救助支架置入率明显更高（2.0[IQR1.0，3.0]与1.0[IQR0，2.0]，p<.010；和37%与14%,p<.001)。在1.48(IQR0.63,3.09)年的中位随访期间，CLTI患者的CD-TLR率（p=0.90）和截肢率（p=0.15）无统计学意义。
结论：在复杂的股动脉CTO中，顺行性再通失败后的逆行对于血管内血运重建是安全的，在有经验的手中，可能会导致不太严重的夹层和较低的支架置入率。然而,考虑到后续持续时间相对较短，两种方法之间的CD-TLR和截肢率没有统计学差异。[德国临床试验注册：DRKS00015277。].
方法：顺行与顺行的连续患者研究了2017年1月至2022年6月间因有症状的外周动脉疾病导致股pop动脉长期慢性完全闭塞(CTO)顺行再通术失败后的逆行血运重建.回顾性病例对照匹配用于使用外周动脉钙化评分系统（PACSS）调整病变长度和钙化。程序性结果包括夹层的严重程度(A型至F型夹层，在血管成形术后，数字分级为0-6，严重程度不断增加），并且在索引手术过程中需要植入支架的数量和位置。此外,随访期间评估了临床驱动的靶病变血运重建(CD-TLR)和主要(踝关节以上)截肢率.
结果：共分析了180例顺行（n=90）与顺行顺行失败后逆行（n=90）。中位患者年龄为76.0岁（四分位距[IQR]67.0，82.0岁），女性为76岁（42.2％）。此外，78例患者（43.3%）有间歇性跛行，而102例（56.7%）表现为慢性威胁肢体缺血（CLTI）。平均病变长度为30.0（IQR24.0，36.0）cm，中度至重度（3.0[IQR2.0，4.0]）病变钙化。血管成形术后的解剖严重程度高于顺行。顺行再通失败后的逆行(4.0[IQR3.0，4.0]与3.0[IQR2.0,4.0]；p<.001)。此外,在顺行策略下，所有节段的支架数量和pop节段的救助支架置入率明显更高（2.0[IQR1.0，3.0]与1.0[IQR0，2.0]，p<.010；和37%与14%,p<.001)。在1.48(IQR0.63,3.09)年的中位随访期间，CLTI患者的CD-TLR率（p=0.90）和截肢率（p=0.15）无统计学意义。
结论：在复杂的股动脉CTO中，顺行性再通失败后的逆行对于血管内血运重建是安全的，在有经验的手中，可能会导致不太严重的夹层和较低的支架置入率。然而,考虑到后续持续时间相对较短，两种方法之间的CD-TLR和截肢率没有统计学差异。[德国临床试验注册：DRKS00015277。].
