Keywords
REVERT technique - endovascular intervention - single-access approach
Introduction
Atherosclerotic cardiovascular diseases, including peripheral artery diseases (PAD), affect over 230 million individuals worldwide, causing premature deaths, limb loss, and significant health care costs.[1]
[2] Endovascular interventions have become the preferred treatment for PAD due to lower procedural risks compared with surgery.[3] The transfemoral approach, incorporating antegrade or retrograde catheterizations, is commonly used for arterial access, especially in complex cases requiring multiple strategies.[4]
Arterial punctures, while essential, carry risks such as dissections, pseudoaneurysm formation, and embolization, which increase with the number of puncture sites.[5]
[6]
[7] The “REVERT” technique offers a single-access approach to address ipsilateral PAD, potentially reducing these risks. However, concerns about femoral artery stress and operator challenges with ipsilateral superficial femoral artery (SFA) catheterization remain.[4]
This study retrospectively evaluates the safety and efficacy of the REVERT technique in patients treated at our institution over the past 3 years.
Materials and Methods
Ethical Considerations
This retrospective study protocol adhered to the principles outlined in the Helsinki Declaration and received approval from the institutional review board under reference number 2022000604–1. Individual informed consent was routinely obtained from all patients for their procedures, but additional consent specific to the study was not required due to the retrospective nature of the research.
Patient Population
Between January 2019 and October 2022, a total of 1,559 lower extremity angiographies were performed at our center for the treatment of PAD. Various arterial access sites, including femoral, axillary, brachial, popliteal, and below-the-knee (BTK) arteries, were used in these PAD interventions, depending on specific clinical scenarios. During this period, 12 patients treated with the REVERT technique were included in the study.
Collection of Patient Data
We evaluated various patient demographic and clinical parameters, including age, gender, presence of acute limb ischemia (ALI), Rutherford classification, iliac artery calcification and tortuosity, history of prior lower extremity interventions, and use of antiplatelet or anticoagulant medications. Additionally, we examined the hemoglobin levels, international normalized ratio (INR), and platelet (PLT) counts from patient records.
Collection of Procedural Data
We also collected and evaluated data on preferred sheath sizes, puncture technique (manual palpation or ultrasound [US] guidance), use of vascular closure devices or manual compression for achieving hemostasis, the side on which the procedures were performed, and the treated vessels.
Complication Evaluation
Subsequently, we assessed primary and secondary complications. All procedures were performed by experienced operators, with the use of US for common femoral artery (CFA) punctures determined by the operator's preference. The significance of complications associated with the techniques used was evaluated using the adverse event classification system of the Society of Interventional Radiology.[8]
Technique
Femoral puncture sites were evaluated by senior nurse practitioners or radiology residents according to institutional protocols. Patients were positioned supine, and femoral artery access was achieved using an 18-gauge hollow needle. For retrograde punctures, the arterial pulse guided site selection, with the needle inserted at a 45-degree angle. Anatomical landmarks or fluoroscopy were used when necessary to locate the femoral head.
When US guidance was applied, a 7.5-Hz linear probe (Sonosite M-Turbo, Bothell, WA, United States) was used, favoring plaque-free segments of the CFA for access. The REVERT technique employed a 0.035-inch stiff glidewire (Terumo, Japan), 5-Fr/6-Fr sheaths (Terumo or Cook, United States), and diagnostic catheters (e.g., Simmons 1/5 or C2 from Boston Scientific).
After diagnostic angiography, a diagnostic catheter formed a Waltman loop and was advanced into the terminal aorta. The wire and catheter were then pulled into the ipsilateral iliac artery and advanced into the SFA. The wire was left in the distal SFA, while the sheath and catheter were removed. Finally, the sheath was reversed to enable antegrade catheterization of the SFA (see [Fig. 1]).
Fig. 1 The reverse catheterization technique involves the following: (A) Advancing a pigtail catheter into the abdominal aorta via a short sheath after right common femoral artery (CFA) puncture for diagnostic angiography; (B) inserting a guiding sheath retrogradely and performing contralateral endovascular treatment (EVT) using the crossover technique; (C) retracting the guiding sheath to the CFA and advancing a DC into the terminal aorta; (D) forming a Waltman loop for ipsilateral catheterization; (E) advancing a 0.035-inch wire and diagnostic catheter (DC) into the ipsilateral iliac and superficial femoral artery (SFA); (F) removing the sheath and DC while leaving the wire in the distal SFA; and (G) reversing the sheath to enable antegrade catheterization of the SFA.
Following the completion of the procedures, hemostasis was achieved through either manual compression or the use of a vascular closure device. It should be noted that, within our institution, the decision to utilize US guidance for arterial access or to select a specific vascular closure device for achieving hemostasis was at the discretion of the experienced interventional radiologist.
Results
This study included 12 patients (mean age: 72 years; 75% male) who underwent the REVERT catheterization technique. Critical ischemia (Rutherford ≥4) was observed in 58.3% of patients, while moderate or severe iliac artery calcification and severe tortuosity were noted in 8.3 and 16.7% patients, respectively. One patient had a previously placed iliac stent. Laboratory values showed a mean hemoglobin of 12.3 g/dL, INR of 1.10, and PLT count of 265,580/mm3. Most patients (91.7%) were on single antiplatelet or anticoagulant therapy, and one (8.3%) was on dual therapy ([Table 1]).
Table 1
Patient demographic and clinical data
|
Variable
|
Percentage (n = 12)
|
|
Mean age (y)
|
72
|
|
Gender, male
|
75 (9)
|
|
Gender, female
|
25 (3)
|
|
Acute limb ischemia (ALI)
|
0 (0)
|
|
Rutherford ≥4
|
58.3 (7)
|
|
Moderate/severe iliac artery calcification
|
8.3 (1)
|
|
Severe iliac artery tortuosity
|
16.7 (2)
|
|
Previously placed iliac artery stent
|
8.3 (1)
|
|
Mean hemoglobin level (g/dL)
|
12.3
|
|
Mean international normalized ratio (INR) value
|
1.10
|
|
Mean platelet count (mm3)
|
265,580
|
|
Single anticoagulant or antiplatelet therapy
|
91.7 (11)
|
|
Dual anticoagulant or antiplatelet therapy
|
8.3 (1)
|
Procedural data revealed that 58.3% of cases used a 5-Fr short sheath, while 33.3% and 8.3% of cases used a 6-Fr short sheath and a 6-Fr long sheath respectively. Puncture techniques involved manual palpation in 58.3% and US guidance in 41.7%. Hemostasis was achieved through manual compression in 91.7% of cases and a vascular closure device in 8.3%. Right-sided diagnosis and treatment were performed in 91.7% of cases, while bilateral treatment was performed in 8.3% ([Table 2]).
Table 2
Procedure data
|
Variable
|
Percentage (n = 12)
|
|
Sheath sizes used
|
|
5 Fr
|
58.3 (7)
|
|
6 Fr
|
33.3 (4)
|
|
6 Fr long
|
8.3 (1)
|
|
Puncture technique
|
|
Palpation
|
58.3 (7)
|
|
Ultrasound guidance
|
41.7 (5)
|
|
Hemostasis method
|
|
Manual compression
|
91.7 (11)
|
|
Vascular closure device
|
8.3 (1)
|
|
Side of treatment
|
|
Right diagnosis and right treatment
|
91.7 (11)
|
|
Right diagnosis and bilateral treatment
|
8.3 (1)
|
Target lesions included femoropopliteal and BTK (FP + BTK) lesions in 33.3%, BTK lesions in 25%, FP lesions in 25%, aortoiliac, femoropopliteal, and below-the-knee (AI + FP + BTK) lesions in 8.3%, and bilateral BTK lesions in another 8.3% ([Table 3]).
Table 3
Target lesions
|
Lesion type
|
Percentage (n = 12)
|
|
Femoropopliteal and below the knee (FP + BTK)
|
33.3 (4)
|
|
Below the knee (BTK)
|
25 (3)
|
|
Femoropopliteal (FP)
|
25 (3)
|
|
Aortoiliac, femoropopliteal, and below-the-knee (AI + FP + BTK)
|
8.3 (1)
|
|
Bilateral below-the-knee (BTK)
|
8.3 (1)
|
Discussion
This study aimed to describe the application of the REVERT technique and demonstrate its safety and feasibility when performed by skilled operators. While retrograde femoral artery puncture is the traditional method for lower extremity angiography, and the antegrade approach allows more direct access for ipsilateral treatments, the REVERT technique offers a single-access solution for treating ipsilateral and bilateral lesions. However, it demands high technical expertise compared with standard approaches.
The REVERT technique has shown comparable efficacy and safety to established methods, with no significant complications reported in our study, consistent with previous findings.[4]
[9]
[10] A single case of sheath kinking was resolved by using a kink-resistant sheath, emphasizing the need for careful equipment selection, particularly in anatomically challenging cases. Operators should remain vigilant for such issues. A representative case is presented in [Fig. 2].
Fig. 2 A representative case demonstrating (A) short segment occlusion of the left anterior tibial artery with distal refilling via superficial collaterals (linear arrow) and occluded left peroneal artery (curved arrow); (B) occluded left dorsalis pedis artery (linear arrow); (C) occluded right anterior tibial and peroneal arteries (arrowhead), with poor posterior tibial artery filling (linear arrow); (D) occlusion beyond the right plantar arch onset (linear arrow); (E) contralateral access and endovascular treatment (EVT) of the left dorsalis pedis artery using a crossover technique; (F) Waltman loop formation for ipsilateral femoral artery catheterization; (G) antegrade catheterization of the ipsilateral superficial femoral artery by reversing the sheath; and (H) balloon angioplasty of the right posterior tibial artery and plantar arch.
The REVERT technique offers a key advantage by reducing the need for multiple punctures, thereby minimizing entry site complications such as pseudoaneurysms and hematomas. This is particularly beneficial for high-risk populations, including those with coagulopathies or advanced atherosclerosis. Procedure success and complication rates are closely tied to the operator's skill and experience. In this study, all procedures were performed by experienced practitioners.
The study is limited by its small sample size, single-center design, and retrospective nature, as well as its dependence on operator expertise. Larger, multicenter prospective studies are required to validate these findings.
Conclusion
The REVERT technique demonstrates potential as a safe and effective method for single-stage endovascular treatment of bilateral or ipsilateral PAD. In this series, the technique was successfully applied without significant complications, aligning with findings from existing literature.
