Skip to main content
NCBI home page
The Cochrane Database of Systematic Reviews logoLink to The Cochrane Database of Systematic Reviews
. 2020 May 29;2020(5):CD013637. doi: 10.1002/14651858.CD013637

Retrograde distal access versus femoral access for below the knee angioplasty

Marcos G Toledo Barros 1,✉, Andre V Fonseca 1, Jorge E Amorim 1, Vladimir Vasconcelos 1
Editor: Cochrane Vascular Group
PMCID: PMC7259753

Objectives

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To compare the effectiveness and safety of retrograde distal access versus conventional femoral access for people undergoing below the knee angioplasty.

Background

Description of the condition

Peripheral artery disease (PAD) is a narrowing of the peripheral arteries caused by atherosclerotic processes leading to stenosis (narrowing) and occlusion (blocking) of non‐cerebral and non‐coronary arteries (Peach 2012). The prevalence of PAD in the general population is about 12% to 14% and it increases in elderly people (Shammas 2007). Reports suggest it reaches 10% in people aged between 55 and 59 years; 20% in people aged between 70 and 75 years; increasing to 60% in people over 85 years old (Meijer 1998; Peach 2012; Shammas 2007). Fowkes 2013 compared world prevalence of PAD, reporting that PAD increased from 164 million people in 2000 to 202 million people in 2010. More than two‐thirds of people with PAD are based in low‐income or middle‐income countries (Fowkes 2013).

Early forms of PAD can progress to critical limb ischemia (CLI), a more severe form of the condition. CLI describes people with typical chronic ischemic rest pain or people with ischemic skin lesions, ulcers or tissue loss, attributed to arterial occlusive disease with symptoms present for more than two weeks (Norgren 2007; Peach 2012; Slovut 2008). People with CLI are classified as Rutherford category 4, 5 or 6 (Norgren 2007; Peach 2012; Slovut 2008) (see Table 1 for Rutherford categories). In people with diabetes, PAD is more aggressive and these people present a risk of major amputation of five to 10 times higher than people without diabetes (Norgren 2007).

1. Classification of peripheral artery disease.

Fontaine clinical classification Rutherford clinical classification
Stage Clinical aspect Grade Category Clinical aspect
I Asymptomatic 0 0 Asymptomatic
IIa Mild claudication I 1 Mild claudication
IIb Moderate–severe claudication I 2 Moderate claudication
I 3 Severe claudication
III Rest pain II 4 Rest pain
IV Arterial ulcer or gangrene — 5 Minor trophic lesion
— 6 Major trophic lesion
Open in a new tab

CLI occurs in 1% to 2% of people with intermittent claudication over five years (Rana 2012). One third of people with CLI have isolated below the knee (BTK) lesions (Gray 2010). A BTK lesion is an atherosclerotic process causing stenosis or occlusions in the infrapopliteal arteries. People with isolated BTK lesions are those with stenotic or occlusive lesions that are only present in the infrapopliteal arteries and do not have combined lesions in the femoral and iliac territories. CLI and isolated BTK lesions are associated with a higher incidence of limb loss when compared with people with multilevel arterial disease (Fernandez 2011). Major amputation occurs in 20% of these patients in one year, and the mortality rate is about 30% (Davies 2012). The main causes of death in these patients are cardiac or cerebrovascular diseases, which is known as a 'cross‐risk' for these patients (Aronow 2008; Peach 2012; Shammas 2007).

Description of the intervention

Endovascular procedures such as angioplasty (with or without stenting) are widely used to treat isolated BTK lesions, aiming to improve blood flow and limb salvage. Limb salvage has been advocated to be more important than patency in people with BTK lesions (Kudo 2006). People with tissue loss appear to achieve better results with revascularization guided by the affected angiosome (a three‐dimensional block of tissue that is supplied blood by a source artery; Taylor 1987) (Kret 2014), although the angiosome concept is still debated. High‐risk patients and evolving endovascular techniques are supporting a shift towards use of endovascular procedures (Jaff 2015; Rana 2012), despite a lack of strong evidence to support this (Adam 2005; Romiti 2008).

The technical success of any angioplasty procedure depends on the ability to cross the target lesion. Failed attempts are underestimated in the literature and failures in the real world appear to be higher than reported (Rana 2012).

The choice of vascular access seems to be critical in BTK angioplasty. There are various options including ipsilateral femoral access, contralateral femoral access and retrograde distal access (Li 2017). Botti 2003 and Spinosa 2003 were the first to describe the retrograde distal access in 2003 where it was originally used as a bailout strategy, when the conventional femoral approach failed (Botti 2003; Goltz 2016; Spinosa 2003).

The most used conventional femoral access techniques for BTK angioplasty are ipsilateral antegrade and contralateral retrograde femoral artery access (Narins 2009).

Contralateral retrograde femoral access is performed through the contralateral common femoral artery (CFA; Figure 1). The use of ultrasound guidance is not mandatory for the puncture. After the target vessel lesion is crossed with the help of standard or support catheters and guidewires, the lesion is treated with balloon angioplasty and a stent if needed (Li 2017; Narins 2009).

1.

1

Open in a new tab

Contralateral femoral access (image created by MG Toledo Barros).

Ipsilateral antegrade femoral access may be performed through the CFA or through the initial part of the superficial femoral artery (SFA; Figure 2) (Li 2017); the punctures are usually performed with ultrasound guidance. After the target vessel lesion is crossed, angioplasty is performed as in retrograde access (Li 2017; Narins 2009).

2.

2

Open in a new tab

Ipsilateral femoral access (image created by MG Toledo Barros).

Retrograde distal access is usually achieved by ultrasound‐guided puncture of the chosen vessel under local anesthesia, commonly the pedal artery (Figure 3), or posterior tibial artery (Figure 4) (Bazan 2014; Goltz 2016). After advancing the guidewire, the lesion is crossed and treated with balloon angioplasty. If the vascular clinicians or interventionalists believe a stent is needed (known as a bailout), then conventional femoral access must be used (Bazan 2014; Manzi 2014).

3.

3

Open in a new tab

Retrograde distal access – pedal artery (image created by MG Toledo Barros).

4.

4

Open in a new tab

Retrograde distal access – posterior tibial artery access (image created by MG Toledo Barros).

How the intervention might work

The most used access techniques for BTK angioplasty are the conventional femoral access techniques of ipsilateral antegrade and contralateral retrograde femoral artery access. The antegrade access provides a straight line to the lesion which facilitates better wire control and torque than the retrograde access (Cragg 2018). People with isolated BTK lesions undergoing angioplasty by femoral access present a failure rate of 20% to cross the lesion (Bazan 2014; Manzi 2014; Rogers 2011). Retrograde access is technically easier and provides better orientation to access the femoral superficial artery (Cragg 2018). Access complications seem to be higher with antegrade access (5.9% with antegrade versus 3.2% with retrograde) (Wheatley 2011).

Retrograde distal access may provide some advantages that can lead to successful crossing of the target lesion: the distal part of the chronic total occlusion (CTO) is supposed to be softer than the proximal cap, which can make the crossing easier (Ozawa 2006): the shorter distance to the target lesion combined with the small vessel diameter provides a better 'pushability' and torque for the wire or catheters (Goltz 2016; Manzi 2014): the concave shape of the distal cap, the size and angle of the collaterals help to keep the wire on the right track (Goltz 2016; Manzi 2014); and a safe access is provided for people with an infected or hostile groin (Goltz 2016; Manzi 2014). Retrograde distal access has a high technical success (69% to 100%), even when used in people with severe lesions and in whom conventional angioplasty has failed (Bazan 2014; Goltz 2016; Manzi 2014; Rogers 2011).

The most dangerous complication of retrograde distal access is the potential for vasospasm and thrombosis. These may occur because of the small vessel diameter, multiple puncture attempts and unfamiliarity with the technique (Bazan 2014). Distal thrombosis is also a potential serious complication with a reported occurrence in the literature of about 2% (Montero‐Baker 2008). Distal thrombosis and damage to the vessel may also result in the possibility of excluding future distal surgical bypass options.

Why it is important to do this review

The incidence of PAD increases exponentially with age (Aronow 2008), and isolated BTK lesions affect high‐risk patients. People with CLI and isolated BTK lesions seem to have a higher risk of major amputation (Gray 2010). These patients have widespread arterial disease, affecting at least two distal arteries with a poor outflow, which results in CLI in the infrapopliteal territory (Fernandez 2011; Jaff 2015; Manzi 2014). People with BTK lesions often have severe comorbidities, such as diabetes and end‐stage renal disease (Goltz 2016; Gray 2010).

The increasing use of endovascular treatment for isolated BTK lesions and the development of new technology has promoted the possibility of new approaches such as distal retrograde access (Bazan 2014; Goltz 2016). The choice of vascular access seems to be crucial in increasing technical success leading to better primary patency and limb salvage rates (Bazan 2014; Rana 2012). Therefore, it is necessary to establish the effectiveness and safety of the retrograde distal access compared to the conventional femoral access to help decision making for clinicians treating, and people undergoing BTK angioplasty.

Objectives

To compare the effectiveness and safety of retrograde distal access versus conventional femoral access for people undergoing below the knee angioplasty.

Methods

Criteria for considering studies for this review

Types of studies

We will include randomized or quasi‐randomized controlled clinical trials comparing people undergoing retrograde distal access versus people undergoing conventional femoral access (ipsilateral antegrade or contralateral retrograde) for BTK angioplasty.

Types of participants

We will include all people undergoing isolated BTK angioplasty with at least one distal patent vessel.

We will include participants undergoing either a primary/first access or a bailout access. We will present the results by subgroups of primary and bailout access.

Types of interventions

We will include studies that compare retrograde distal access with conventional femoral access (ipsilateral antegrade or contralateral retrograde) for BTK angioplasty.

Types of outcome measures

Primary outcomes

  • Technical success of angioplasty procedure: defined as the ability to cross an occluded segment and successfully open the artery with a residual stenosis of less than 30%.

  • Major procedural complications: major bleeding, retroperitoneal bleeding, embolization or thrombosis resulting in partial or total arterial occlusion.

Secondary outcomes

  • Mortality rate at 30 days after procedure.

  • Amputation‐free survival at six and 12 months: defined as amputation of the trial leg above the ankle.

  • Primary patency: defined as less than 50% loss of luminal diameter at the treated site at one and 12 months, verified by Doppler ultrasound or angiography.

  • Minor procedural complications: hematoma, pseudoaneurysm, arteriovenous fistula or access‐site infection.

  • Wound healing: as defined by the studies at one and 12 months.

Search methods for identification of studies

We will place no restrictions on language or publication status. We will arrange translation of trial reports if required.

Electronic searches

The Cochrane Vascular Information Specialist aims to identify all relevant randomized controlled trials and quasi‐randomized controlled trials regardless of language or publication status (published, unpublished, in press or in progress).

The Information Specialist will search the following databases for relevant trials.

  • The Cochrane Vascular Specialised Register via the Cochrane Register of Studies (CRS‐Web).

  • The Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO).

  • MEDLINE (Ovid MEDLINE Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE) (1946 onwards).

  • Embase Ovid (1974 onwards).

  • CINAHL EBSCO (1982 onwards).

The Information Specialist has devised a draft search strategy for CENTRAL, which is displayed in Appendix 1. This will be used as the basis for search strategies for the other databases listed.

The Information Specialist will search the following trials registries.

  • ClinicalTrials.gov (clinicaltrials.gov).

  • World Health Organization International Clinical Trials Registry Platform (who.int/trialsearch).

Searching other resources

To identify further published, unpublished and ongoing trials, we will:

  • search the reference lists of identified relevant studies and reviews;

  • contact study authors and experts in the field;

  • contact relevant manufacturers; and

  • use Science Citation Index Cited Reference Search for forward tracking of important articles.

Data collection and analysis

Selection of studies

Two review authors (MGBT, AVF) will independently screen titles and abstracts of the references obtained as a result of our searching activities and will exclude obviously irrelevant reports and remove duplicates. We will retrieve the full‐text articles for the remaining references and two review authors (MGBT, AVF) will independently screen the full‐text articles, identify studies for inclusion, and identify and record reasons for exclusion of the ineligible studies in the 'Characteristics of excluded studies' table. We will resolve any disagreements through discussion or, if required, we will consult a third review author (VV). We will collate multiple reports of the same study so that each study, not each reference, is the unit of interest in the review. We will record the selection process and complete a PRISMA flow diagram.

Data extraction and management

Two review authors (MGBT, AVF) will independently extract the following data from eligible studies, and record the information on standard data extraction forms:

  • participants: sample size, age, sex, number of participants originally allocated to each treatment group, diagnostic criteria used for PAD, numbers of participants in each group. CLI classification as clinical presentation using Rutherford (Table 1), Fontaine (Fontaine 1954) (Table 1), or WIfI (Mills 2014);

  • intervention: type of anesthesia, puncture technique, angioplasty technique and use of stent as first choice or as a bailout strategy, length of lesion treated;

  • outcomes: number of participants in each group with outcome events, including: angioplasty technical success, major procedural complications, death, amputation‐free survival, primary patency, minor procedural complications and wound healing;

  • withdrawals and adverse effects;

  • length of follow‐up;

  • types of data analyses (e.g. intention‐to‐treat, per‐protocol);

  • any additional important information.

We will resolve any disagreements between review authors by discussion.

Assessment of risk of bias in included studies

Two review authors (MGBT, AVF) will independently assess the risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We will resolve any disagreements by discussion or by involving another review author (VV). We will assess the risk of bias according to the following domains.

  • Random sequence generation.

  • Allocation concealment.

  • Blinding of participants and personnel.

  • Blinding of outcome assessment.

  • Incomplete outcome data.

  • Selective outcome reporting.

  • Other bias.

We will grade the risk of bias for each domain as high, low or unclear and provide information from the study report together with a justification for our judgment in the 'Risk of bias' tables.

Measures of treatment effect

We will calculate the risk ratio (RR) and 95% confidence intervals (CIs) for dichotomous variables. In the event that study authors do not have the necessary information available, we will present any data from primary studies that are not parametric (e.g. effects reported as medians, quartiles, etc.) or without sufficient statistical information (e.g. standard deviations, numbers of participants, etc.) in additional tables.

Unit of analysis issues

We will use the individual participant as our unit of analysis (unit to be randomized for interventions to be compared), that is, the number of observations in the analysis should match the number of individuals randomized. For trials that consider multiple interventions in the same group, we will analyze only the partial data of interest.

Dealing with missing data

We will request any missing data from the original investigators, if appropriate. In case of non‐response, irrespective of the type of data, we will report dropout rates in the 'Characteristics of included studies' table, and we will use intention‐to‐treat analysis.

Assessment of heterogeneity

We will quantify inconsistency among the pooled estimates using the I2 statistic (where I2 = ((Q – df)/Q) × 100%, where Q is the Chi2 statistic, and df represents the degree of freedom). This illustrates the percentage of the variability in effect estimates resulting from heterogeneity rather than sampling error (Higgins 2011). We will interpret the thresholds for the I2 statistic as follows: 0% to 25% = low heterogeneity; 25% to 75% = moderate heterogeneity; and more than 75% = substantial heterogeneity (Higgins 2003).

Assessment of reporting biases

We will assess reporting biases or small‐study effects by drawing a funnel plot (trial effect versus trial size) if we include more than 10 studies in the review (Higgins 2011).

Data synthesis

We will compute pooled estimates of the intervention effect for each outcome under a fixed‐effect model using Review Manager 5 (Review Manager 2014), when we do not identify substantial heterogeneity (I2 statistic greater than 75%). If we identify substantial heterogeneity, we will perform a random‐effects model analysis. If it is not possible or appropriate to conduct a meta‐analysis, we will report the study results narratively.

Subgroup analysis and investigation of heterogeneity

If an adequate number of studies are identified, we will perform subgroup analyses according to:

  • diabetes;

  • chronic renal failure undergoing dialysis;

  • CLI classification as described by the authors: Rutherford classification (Table 1), Fontaine classification (Table 1), or WIfI classification (Mills 2014);

  • retrograde distal access as primary access or as a bailout strategy;

  • ipsilateral antegrade femoral access or contralateral retrograde femoral access;

  • length of lesions as described by the study authors or using the Global Anatomic Staging System (GLASS) (Conte 2019), if possible.

If we find substantial heterogeneity, and there are sufficient data, we will investigate the possible causes by further exploring the impact of the condition of the individuals and interventions (i.e. participant characteristics, intervention material) using subgroup analysis. We will test for subgroup differences using interaction tests.

Sensitivity analysis

If there are an adequate number of studies, we will perform a sensitivity analysis based on the risk of bias domains randomization (allocation concealment) (high, low, or unclear) and blinding of outcome assessment (high, low, or unclear). Since concealment of allocation and blinding are difficult for this type of intervention, if necessary, we will carry out sensitivity analysis by excluding trials with high or unclear risk of as defined by the 'Risk of bias' table for these domains. If we identify participants for whom the randomized primary intervention failed and who were immediately crossed over to bail out access, we will perform a sensitivity analysis of the treatment which was actually performed (per‐protocol analysis). We will present these results and compare them with the overall findings.

Summary of findings and assessment of certainty of the evidence

We will prepare a 'Summary of findings' table using the GRADEpro Guideline Development Tool to present the key information found in this review (www.gradepro.org). We have included a draft table in this protocol (Table 2). We will compare retrograde distal access versus femoral access in people undergoing BTK angioplasty. We will include outcomes as listed in Types of outcome measures. These data will be presented at the most clinically relevant time point. We will use the GRADE approach to assess the certainty of the evidence for each outcome (Atkins 2004). We will assign one of four levels of certainty: high, moderate, low or very low, based on overall risk of bias, directness of the evidence, inconsistency of results, precision of the estimates and risk of publication bias as previously described (Higgins 2011). We intend to base this table on methods described in Chapter 11 and Chapter 12 of the Cochrane Handbook for Systematic Reviews of Interventions, and we will justify any departures from the standard methods (Atkins 2004; Higgins 2011).

2. Is retrograde distal access more effective than femoral access for below the knee angioplasty?
Retrograde distal access versus femoral access for below the knee angioplasty
Patient or population: people undergoing isolated BTK angioplasty with ≥ 1 distal patent vessel
Settings: hospital
Intervention: retrograde distal access (Figure 3; Figure 4)
Comparison: conventional femoral access (Figure 1; Figure 2)
Outcomes Anticipated absolute effects* (95% CI) Relative effect
(95% CI) No of participants
(studies) Certainty of the evidence
(GRADE) Comments
Risk with conventional femoral access Risk with retrograde distal access
Technical success of angioplasty procedure
(follow‐up)		 Study population RR [value] ([value] to [value]) [value]
([value]) ⊕⊝⊝⊝
Very low
⊕⊕⊝⊝
Low
⊕⊕⊕⊝
Moderate
⊕⊕⊕⊕
High 		—
[value] per 1000 [value] per 1000
Major procedural complications
(follow‐up)		 Study population RR [value] ([value] to [value]) [value]
([value]) ⊕⊝⊝⊝
Very low
⊕⊕⊝⊝
Low
⊕⊕⊕⊝
Moderate
⊕⊕⊕⊕
High 		—
[value] per 1000 [value] per 1000
Mortality
(follow‐up)		 Study population RR [value] ([value] to [value]) [value]
([value]) ⊕⊝⊝⊝
Very low
⊕⊕⊝⊝
Low
⊕⊕⊕⊝
Moderate
⊕⊕⊕⊕
High 		—
[value] per 1000 [value] per 1000
([value] to [value])
Amputation free survival
(follow‐up)		 Study population RR [value] ([value] to [value]) [value]
([value]) ⊕⊝⊝⊝
Very low
⊕⊕⊝⊝
Low
⊕⊕⊕⊝
Moderate
⊕⊕⊕⊕
High 		—
[value] per 1000 [value] per 1000
([value] to [value])
Primary patency
(follow‐up)		 Study population RR [value] ([value] to [value]) [value]
([value]) ⊕⊝⊝⊝
Very low
⊕⊕⊝⊝
Low
⊕⊕⊕⊝
Moderate
⊕⊕⊕⊕
High 		—
[value] per 1000 [value] per 1000
([value] to [value])
Minor procedural complications
(follow‐up)		 Study population RR [value] ([value] to [value]) [value]
([value]) ⊕⊝⊝⊝
Very low
⊕⊕⊝⊝
Low
⊕⊕⊕⊝
Moderate
⊕⊕⊕⊕
High 		—
[value] per 1000 [value] per 1000
([value] to [value])
Wound healing
(follow‐up)		 Study population RR [value] ([value] to [value]) [value]
([value]) ⊕⊝⊝⊝
Very low
⊕⊕⊝⊝
Low
⊕⊕⊕⊝
Moderate
⊕⊕⊕⊕
High 		—
[value] per 1000 [value] per 1000
([value] to [value])
*The risk with the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
BTK: below the knee; CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
Open in a new tab

History

Protocol first published: Issue 5, 2020

Notes

Parts of the methods section of this protocol are based on a standard template established by Cochrane Vascular.

Acknowledgements

We wish to thank Cochrane Vascular for their assistance with this protocol, especially Dr Cathryn Broderick and Dr Marlene Stewart.

The review authors, and the Cochrane Vascular editorial base, are grateful to the following peer reviewers for their time and comments:

  • Danial Sayyad, Iran, consumer reviewer;

  • Dheeraj Rajan, MD, FRCPC, FSIR, FACR, Head and Professor, Division of Vascular & Interventional Radiology, Department of Medical Imaging, University of Toronto, Canada;

  • Dr Neghal Kandiyil, MRCS, FRCR, PhD, Consultant Interventional Radiologist and Honorary lecturer, University of Leicester, University Hospitals of Leicester NHS Trust, UK;

  • Alok Tiwari, MBBS, MS, FRCSEd, Consultant Vascular and Endovascular Surgeon, Department of Vascular Surgery, Queen Elizabeth Hospital, Birmingham, UK.

Appendices

Appendix 1. CENTRAL search strategy

#1 MESH DESCRIPTOR Arteriosclerosis 946

#2 MESH DESCRIPTOR Arteriolosclerosis EXPLODE ALL TREES 0

#3 MESH DESCRIPTOR Arteriosclerosis Obliterans 78

#4 MESH DESCRIPTOR Atherosclerosis 1057

#5 MESH DESCRIPTOR Arterial Occlusive Diseases 818

#6 MESH DESCRIPTOR Intermittent Claudication 823

#7 MESH DESCRIPTOR Ischemia 1531

#8 MESH DESCRIPTOR Peripheral Vascular Diseases EXPLODE ALL TREES 2774

#9 (atherosclero* or arteriosclero* or PVD or PAOD or PAD ):TI,AB,KY 12114

#10 ((arter* or vascular or vein* or veno* or peripher*) near3 (occlus* or reocclus* or re‐occlus* or steno* or restenos* or obstruct* or lesio* or block* or harden* or stiffen* or obliter*) ):TI,AB,KY 10592

#11 (peripheral near3 dis*):TI,AB,KY 4830

#12 (claudic* or IC):TI,AB,KY 4091

#13 (isch* or CLI):TI,AB,KY 32018

#14 arteriopathic:TI,AB,KY 7

#15 dysvascular*:TI,AB,KY 21

#16 (leg near3 (occlus* or reocclus* or re‐occlus* or steno* or restenos* or obstruct* or lesio* or block* or harden* or stiffen* or obliter*) ):TI,AB,KY 131

#17 (limb near3 (occlus* or reocclus* or re‐occlus* or steno* or restenos* or obstruct* or lesio* or block* or harden* or stiffen* or obliter*) ):TI,AB,KY 220

#18 ((lower near3 extrem*) near3 (occlus* or reocclus* or re‐occlus* or steno* or restenos* or obstruct* or lesio* or block* or harden* or stiffen* or obliter*) ):TI,AB,KY 106

#19 ((iliac or femoral or popliteal or femoro* or fempop* or crural) near3(occlus* or reocclus* or re‐occlus* or steno* or restenos* or obstruct* or lesio* or block* or harden* or stiffen* or obliter*) ):TI,AB,KY 1527

#20 restenosis:TI,AB,KY 3059

#21 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 59052

#22 MESH DESCRIPTOR Angioplasty EXPLODE ALL TREES 4285

#23 MESH DESCRIPTOR Endovascular Procedures 307

#24 (angioplas* or percutan* or PTA):TI,AB,KY 17916

#25 valvuloplasty:TI,AB,KY 186

#26 (recanali* or revascular*):TI,AB,KY 9780

#27 dilat*:TI,AB,KY 9471

#28 (balloon or baloon):TI,AB,KY 8413

#29 endovascular:TI,AB,KY 2514

#30 #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 35976

#31 #21 AND #30 11549

#32 MESH DESCRIPTOR Knee EXPLODE ALL TREES 710

#33 Knee:TI,AB,KY 19192

#34 MESH DESCRIPTOR Lower Extremity EXPLODE ALL TREES WITH QUALIFIERS SU 683

#35 ipsilateral:TI,AB,KY 2034

#36 antegrade:TI,AB,KY 505

#37 (vascular access):TI,AB,KY 1143

#38 (lower leg):TI,AB,KY 619

#39 (distal access):TI,AB,KY 2

#40 (distal approach):TI,AB,KY 9

#41 (femoral access):TI,AB,KY 203

#42 (femoral approach):TI,AB,KY 135

#43 (femoral artery access):TI,AB,KY 38

#44 #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 23935

#45 #31 AND #44 551

Contributions of authors

MGTB: protocol drafting, trial selection, data extraction, data interpretation, review drafting, future review updates.

AVF: protocol drafting, trial selection, data extraction, future review updates.

JEA: protocol drafting, data interpretation, review drafting.

VV: protocol drafting, trial selection, data interpretation, data analysis, future review updates.

Sources of support

Internal sources

  • No sources of support supplied

External sources

  • Chief Scientist Office, Scottish Government Health Directorates, The Scottish Government, UK

    The Cochrane Vascular editorial base is supported by the Chief Scientist Office.

Declarations of interest

MGTB: none.

AVF: none.

JEA: none.

VV: none.

New

References

Additional references

Adam 2005

  1. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005; 366(9501):1925-34. [PMID: ] [DOI] [PubMed] [Google Scholar]

Aronow 2008

  1. Aronow H. Peripheral arterial disease in the elderly: recognition and management. American Journal of Cardiovascular Drugs 2008; 8(6):353-64. [PMID: ] [DOI] [PubMed] [Google Scholar]

Atkins 2004

  1. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328(7454):1490-4. [DOI] [PMC free article] [PubMed] [Google Scholar]

Bazan 2014

  1. Bazan HA, Le L, Donovan M, Sidhom T, Smith TA, Sternbergh WC 3rd. Retrograde pedal access for patients with critical limb ischemia. Journal of Vascular Surgery 2014; 60(2):375-81. [PMID: ] [DOI] [PubMed] [Google Scholar]

Botti 2003

  1. Botti CF Jr, Ansel GM, Silver MJ, Barker BJ, South S. Percutaneous retrograde tibial access in limb salvage. Journal of Endovascular Therapy 2003; 10(3):614-8. [PMID: ] [DOI] [PubMed] [Google Scholar]

Conte 2019

  1. Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. Journal of vascular surgery 2019; 69(6S):3S-125S.e40. [PMID: ] [DOI] [PMC free article] [PubMed] [Google Scholar]

Cragg 2018

  1. Cragg J, Lowry D, Hopkins J, Parker D, Kay M, Duddy M, et al. Safety and outcomes of ipsilateral antegrade angioplasty for femoropopliteal disease. Vascular and Endovascular Surgery 2018; 52(2):93-7. [PMID: ] [DOI] [PubMed] [Google Scholar]

Davies 2012

  1. Davies MG. Critical limb ischemia: epidemiology. Methodist DeBakey Cardiovascular Journal 2012; 8(4):10-4. [PMID: ] [DOI] [PMC free article] [PubMed] [Google Scholar]

Fernandez 2011

  1. Fernandez N, McEnaney R, Marone LK, Rhee RY, Leers S, Makaroun M, et al. Multilevel versus isolated endovascular tibial interventions for critical limb ischemia. Journal of Vascular Surgery 2011; 54(3):722-9. [PMID: ] [DOI] [PMC free article] [PubMed] [Google Scholar]

Fontaine 1954

  1. Fontaine R, Kim M, Kieny R. Surgical treatment of peripheral circulation disorders [Die chirurgische Behandlung der peripheren Durchblutungsstorungen]. Helvetica Chirurgica Acta 1954; 21(5-6):499-533. [PMID: ] [PubMed] [Google Scholar]

Fowkes 2013

  1. Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 2013; 382(9901):1329-40. [PMID: ] [DOI] [PubMed] [Google Scholar]

Goltz 2016

  1. Goltz JP, Planert M, Horn M, Wiedner M, Kleemann M, Barkhausen J, et al. Retrograde transpedal access for revascularization of below-the-knee arteries in patients with critical limb ischemia after an unsuccessful antegrade transfemoral approach [Retrograd transpedale revaskularisierung kruraler arterien bei patienten mit kritischer extremitatenischamie und gescheitertem antegraden revaskularisierungsversuch]. RoFo 2016; 188(10):940-8. [PMID: ] [DOI] [PubMed] [Google Scholar]

Gray 2010

  1. Gray BH, Grant AA, Kalbaugh CA, Blackhurst DW, Langan EM 3rd, Taylor SA, et al. The impact of isolated tibial disease on outcomes in the critical limb ischemic population. Annals of Vascular Surgery 2010; 24(3):349-59. [PMID: ] [DOI] [PubMed] [Google Scholar]

Higgins 2003

  1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ (Clinical Research Ed.) 2003; 327(7414):557-60. [DOI] [PMC free article] [PubMed] [Google Scholar]

Higgins 2011

  1. Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.

Jaff 2015

  1. Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, et al. An update on methods for revascularization and expansion of the TASC Lesion Classification to include below-the-knee arteries: a supplement to the Inter-Society consensus for the management of peripheral arterial disease (TASC II). Journal of Endovascular Therapy 2015; 22(5):663-77. [PMID: ] [DOI] [PubMed] [Google Scholar]

Kret 2014

  1. Kret MR, Cheng D, Azarbal AF, Mitchell EL, Liem TK, Moneta GL, et al. Utility of direct angiosome revascularization and runoff scores in predicting outcomes in patients undergoing revascularization for critical limb ischemia. Journal of Vascular Surgery 2014; 59(1):121-8. [PMID: ] [DOI] [PubMed] [Google Scholar]

Kudo 2006

  1. Kudo T, Chandra FA, Kwun WH, Haas BT, Ahn SS. Changing pattern of surgical revascularization for critical limb ischemia over 12 years: endovascular vs. open bypass surgery. Journal of Vascular Surgery 2006; 44(2):304-13. [PMID: ] [DOI] [PubMed] [Google Scholar]

Li 2017

  1. Li Y, Esmail A, Donas KP, Pitoulias G, Torsello G, Bisdas T, et al. Antegrade vs crossover femoral artery access in the endovascular treatment of isolated below-the-knee lesions in patients with critical limb ischemia. Journal of Endovascular Therapy 2017; 24(3):331-6. [PMID: ] [DOI] [PubMed] [Google Scholar]

Manzi 2014

  1. Manzi M, Palena LM. Treating calf and pedal vessel disease: the extremes of intervention. Seminars in Interventional Radiology 2014; 31(4):313-9. [PMID: ] [DOI] [PMC free article] [PubMed] [Google Scholar]

Meijer 1998

  1. Meijer WT, Hoes AW, Rutgers D, Bots ML, Hofman A, Grobbee DE. Peripheral arterial disease in the elderly: the Rotterdam Study. Arteriosclerosis, Thrombosis, and Vascular Biology 1998; 18(2):185-92. [PMID: ] [DOI] [PubMed] [Google Scholar]

Mills 2014

  1. Mills JL Sr, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). Journal of Vascular Surgery 2014; 59(1):220-34.e1-2. [PMID: ] [DOI] [PubMed] [Google Scholar]

Montero‐Baker 2008

  1. Montero-Baker M, Schmidt A, Braunlich S, Ulrich M, Thieme M, Biamino G, et al. Retrograde approach for complex popliteal and tibioperoneal occlusions. Journal of Endovascular Therapy 2008; 15(5):594-604. [PMID: ] [DOI] [PubMed] [Google Scholar]

Narins 2009

  1. Narins CR. Access strategies for peripheral arterial intervention. Cardiology Journal 2009; 16(1):88-97. [PMID: ] [PubMed] [Google Scholar]

Norgren 2007

  1. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society consensus for the management of peripheral arterial disease (TASC II). Journal of Vascular Surgery 2007; 45 Suppl S:S5-67. [PMID: ] [DOI] [PubMed] [Google Scholar]

Ozawa 2006

  1. Ozawa N. A new understanding of chronic total occlusion from a novel PCI technique that involves a retrograde approach to the right coronary artery via a septal branch and passing of the guidewire to a guiding catheter on the other side of the lesion. Catheterization and Cardiovascular Interventions 2006; 68(6):907-13. [PMID: ] [DOI] [PubMed] [Google Scholar]

Peach 2012

  1. Peach G, Griffin M, Jones KG, Thompson MM, Hinchliffe RJ. Diagnosis and management of peripheral arterial disease. BMJ (Clinical Research Ed.) 2012; 345:e5208. [PMID: ] [DOI] [PubMed] [Google Scholar]

Rana 2012

  1. Rana MA, Gloviczki P. Endovascular interventions for infrapopliteal arterial disease: an update. Seminars in Vascular Surgery 2012; 25(1):29-34. [PMID: ] [DOI] [PubMed] [Google Scholar]

Review Manager 2014 [Computer program]

  1. The Nordic Cochrane Centre, The Cochrane Collaboration Review Manager 5 (RevMan 5). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Rogers 2011

  1. Rogers RK, Dattilo PB, Garcia JA, Tsai T, Casserly IP. Retrograde approach to recanalization of complex tibial disease. Catheterization and Cardiovascular Interventions 2011; 77(6):915-25. [PMID: ] [DOI] [PubMed] [Google Scholar]

Romiti 2008

  1. Romiti M, Albers M, Brochado-Neto FC, Durazzo AE, Pereira CA, De Luccia N. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. Journal of Vascular Surgery 2008; 47(5):975-81. [PMID: ] [DOI] [PubMed] [Google Scholar]

Shammas 2007

  1. Shammas NW. Epidemiology, classification, and modifiable risk factors of peripheral arterial disease. Vascular Health and Risk Management 2007; 3(2):229-34. [PMID: ] [DOI] [PMC free article] [PubMed] [Google Scholar]

Slovut 2008

  1. Slovut DP, Sullivan TM. Critical limb ischemia: medical and surgical management. Vascular Medicine (London, England) 2008; 13(3):281-91. [PMID: ] [DOI] [PubMed] [Google Scholar]

Spinosa 2003

  1. Spinosa DJ, Leung DA, Harthun NL, Cage DL, Fritz Angle J, Hagspiel KD, et al. Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion. Journal of Vascular and Interventional Radiology 2003; 14(11):1449-54. [PMID: ] [DOI] [PubMed] [Google Scholar]

Taylor 1987

  1. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. British Journal of Plastic Surgery 1987; 40(2):113-41. [PMID: ] [DOI] [PubMed] [Google Scholar]

Wheatley 2011

  1. Wheatley BJ, Mansour MA, Grossman PM, Munir K, Cali RF, Gorsuch JM, et al. Complication rates for percutaneous lower extremity arterial antegrade access. Archives of Surgery (Chicago, Ill. : 1960) 2011; 146(4):432-5. [PMID: ] [DOI] [PubMed] [Google Scholar]

Articles from The Cochrane Database of Systematic Reviews are provided here courtesy of Wiley

RESOURCES