(IP155) The Role of Pedal Access as an Adjunct to Femoral Access For Challenging Lesions in Chronic Limb-Threatening Ischemia.

Objectives: Infrainguinal bypass and peripheral vascular intervention (PVI) are critical for limb salvage in patients with chronic limb-threatening ischemia (CLTI). While traditional femoral access is commonly used in PVI, alternative accesses have emerged to address challenging arterial occlusions and specific anatomic scenarios. The pedal approach can provide notable advantages in selected cases, including easier crossability and improved pushability through smaller-diameter tibial vessels. Using the VQI database, this study compares procedural success and early complications between combined femoral and pedal access (Fem+Pedal) vs. femoral-only (Fem-Only).

Methods: A retrospective analysis of patients undergoing infrainguinal PVI in the VQI database (2016-2024). We included only CLTI patients, defined as ischemic rest pain or tissue loss, with TransAtlantic Inter-Society Consensus (TASC II) class D lesions. Our primary outcomes were technical failure and access site complications (hematoma, stenosis/occlusion, infection, pseudoaneurysm, or arteriovenous fistula). Secondary outcomes were target lesion dissection, vessel perforation, and in-hospital major adverse limb events (MALE) (defined as major amputation or reintervention). Multivariate logistic regression was utilized to adjust for potential confounders.

Results: 1,925(9.2%) and 19,034(90.8%) patients underwent PVI via Fem+Pedal or Fem-Only access, respectively. In the Fem-Only group, 80% of access was retrograde. In the Fem+Pedal group, there were two access sites: one femoral (with contralateral retrograde being the most common, 65%) and one pedal (with dorsal pedal artery being the most common, 55%). Patients in the Fem-Only group were more likely to present with rest pain, have femoral-popliteal lesions, and undergo balloon angioplasty. Those in the Fem+Pedal group were more likely to present with tissue loss, have femorotibial lesions, undergo stent placement, and have multi-level treatment(TableI). Multivariate analysis showed no significant difference between Fem-Only and Fem+Pedal groups in terms of technical failure (aOR=1.17[95%CI:0.99-1.38];P=0.06) or access site complications (aOR=1.3[95%CI:0.98-1.75];P=0.07). However, the Fem+Pedal group was associated with a higher risk of dissection (aOR=1.8[95%CI:1.4-2.3];P < 0.001) and perforation (aOR=3.9[95%CI:2.54-6.03];P < 0.001). While there were no difference in MALE, the Fem+Pedal group had a lower risk of major amputation (aOR=0.68[95%CI:0.48-0.96];P=0.03) compared to the Fem-Only group(TableII).

Conclusions: This multi-institutional study found that pedal access in patients with CLTI and TASCII-D lesions is an important adjunct to traditional femoral access. There were no significant differences in technical failure or access site complications. However, pedal access was associated with a higher risk of dissection and perforation. These findings emphasize that pedal access is viable for carefully selected patients with challenging occlusions and crossing difficulty. Future prospective studies are needed to validate our outcomes.