Radial-to-Femoral Hybrid Approach for Limb Salvage in Critical Infrarenal Aortic Stenosis

Background
Critical limb ischemia in patients under 65 presents unique diagnostic and therapeutic challenges, particularly when caused by infrarenal aortic stenosis. Conventional femoral access becomes impossible when bilateral femoral pulses are absent.

Case Presentation: We report a case of a 62-year-old male presenting with severe claudication, critical limb ischemia, and arterial ulcers. Angiography revealed critical infrarenal aortic stenosis with absent bilateral femoral pulses, eliminating standard access routes. Using a hybrid radial-to-femoral approach, initial angioplasty was performed via radial access, restoring femoral pulses and allowing completion via femoral access with stent deployment.

Conclusion: This case demonstrates that innovative access strategies can mean the difference between amputation and limb salvage. When traditional approaches are unavailable, adaptive procedural planning enables successful revascularization even in technically challenging scenarios.

Keywords: Critical limb ischemia, infrarenal aortic stenosis, radial access, limb salvage, peripheral arterial disease, hybrid endovascular technique

Introduction

Peripheral arterial disease (PAD) with critical limb ischemia represents a limb-threatening condition requiring urgent intervention. In younger patients (under 65 years), the disease progression is typically more aggressive, with studies showing a 24% higher amputation risk compared to older populations. This aggressive trajectory makes timely revascularization critical for limb salvage and functional recovery.

Endovascular interventions for aortoiliac occlusive disease traditionally rely on femoral artery access. However, when severe infrarenal aortic stenosis completely obliterates distal flow, standard access routes become impossible. In these scenarios, alternative approaches are necessary to achieve successful revascularization.

This case report illustrates a hybrid radial-to-femoral technique for managing critical infrarenal aortic stenosis when conventional femoral access was unavailable, highlighting the importance of procedural versatility in complex vascular interventions.

Case Presentation

Patient Information

A 62-year-old male presented to our cardiology department with progressive symptoms of severe claudication and critical limb ischemia. The patient reported inability to walk more than a few meters without significant pain and had developed non-healing arterial ulcers on both lower extremities.

Clinical Findings

On examination, the patient demonstrated:

Severe bilateral lower extremity claudication
Arterial ulcers consistent with critical limb ischemia
Absent bilateral femoral pulses—a critical finding indicating severe proximal obstruction
Cool lower extremities with poor capillary refill
No palpable pedal pulses bilaterally

The absence of femoral pulses raised immediate concern about procedural access for potential endovascular intervention.

Diagnostic Assessment

Angiography revealed:

Critical stenosis of the infrarenal aorta with near-complete occlusion
Severely reduced distal arterial flow
Patent distal vessels suitable for revascularization if proximal flow could be restored
No alternative collateral pathways providing adequate perfusion
Figure 1: Pre-intervention angiography demonstrating critical infrarenal aortic stenosis with severe flow limitation and absent bilateral femoral pulses

Clinical Risk Stratification:

Given the patient’s age (under 65) and aggressive disease presentation, the 24% elevated amputation risk made immediate intervention imperative. Without successful revascularization, bilateral amputation was highly probable within months.

Therapeutic Intervention

The patient underwent endovascular intervention with a novel hybrid approach necessitated by anatomical constraints.

Procedural Challenge:

Standard femoral access—the conventional approach for aortic interventions—was impossible due to absent femoral pulses. The critical stenosis had completely eliminated distal arterial flow, making femoral puncture unfeasible.

Innovative Solution: Hybrid Radial-to-Femoral Approach

Phase 1: Radial Access Angioplasty

Right radial (wrist) artery access obtained
Diagnostic catheter advanced retrograde through the brachial and subclavian arteries into the thoracic aorta
Catheter navigated down the descending aorta to the site of infrarenal stenosis
Guidewire carefully advanced across the critical stenosis
Balloon angioplasty catheter positioned at the stenotic segment
Sequential balloon inflations performed to dilate the infrarenal aorta

Critical Moment:

Upon successful dilation of the stenosis, bilateral femoral pulses immediately returned—a dramatic and clinically significant finding indicating restoration of distal arterial flow.

Phase 2: Femoral Access Completion

With femoral pulses now palpable:

Right femoral artery access obtained
Upsized access achieved for larger device delivery
Self-expanding wallstent deployed across the infrarenal aortic stenosis
Final angiography confirmed excellent stent deployment with restored flow
Both femoral pulses remained strong and palpable
Figure 2: Intra-procedural image showing self-expanding wallstent deployment across the infrarenal aortic stenosis following successful radial access angioplasty

Outcome and Follow-up

Immediate Post-Procedure:

The results were remarkable:

Patient ambulating independently in the hospital corridor within 24 hours
Complete resolution of rest pain
Strong bilateral femoral and pedal pulses
Improved lower extremity perfusion with warmer skin temperature
Figure 3: Post-intervention angiography demonstrating excellent stent expansion with complete restoration of arterial flow and palpable bilateral femoral pulses

Hospital Course:

No procedural complications
Progressive improvement in mobility
Arterial ulcers beginning to show signs of healing
Discharged on post-procedure day 3 in stable condition

Follow-up (Outpatient):

At subsequent follow-up visits:

Patient walking 2 to 3 kilometers daily without symptoms
Complete healing of arterial ulcers
Maintained strong bilateral pulses
No claudication symptoms
Full functional recovery with excellent quality of life

The patient avoided:

Bilateral amputation
Open surgical aortic reconstruction
Prolonged hospitalization
Permanent disability

Discussion

Significance of the Case

This case highlights several critical aspects of complex vascular interventions:

Anatomical Challenges:

Critical infrarenal aortic stenosis with absent femoral pulses presents a unique technical challenge. Standard femoral access—the workhorse approach for aortoiliac interventions—becomes impossible when the very pathology requiring treatment prevents access to the treatment site.

Age-Specific Risk in Critical Limb Ischemia:

Younger patients with PAD face distinct challenges:

More aggressive disease progression
24% higher amputation risk compared to older populations
Greater functional impact due to active lifestyle requirements
Longer life expectancy making limb salvage even more crucial

The Hybrid Radial-to-Femoral Technique:

This case demonstrates procedural innovation when faced with anatomical constraints:

Step 1 (Radial Approach): Using transradial access allowed navigation from the upper extremity arterial system down to the infrarenal aorta, bypassing the need for femoral pulses entirely.

Step 2 (Flow Restoration): Initial balloon angioplasty restored sufficient flow to generate palpable femoral pulses—essentially creating the access route needed for definitive treatment.

Step 3 (Femoral Completion): With femoral access now possible, larger devices could be delivered for optimal stent deployment.

Crisis Management and Adaptive Planning:

“This case demonstrates how adaptive procedural planning can mean the difference between amputation and full recovery,” said Dr. Gyana Ranjan Nayak. “When traditional access routes are unavailable, interventional cardiologists must have alternative strategies ready to save both limbs and lives.”

The decision to pursue this hybrid approach was based on:

Clinical urgency: High amputation risk without intervention
Technical feasibility: Radial access capable of reaching target lesion
Anatomical suitability: Viable distal vessels if proximal flow restored
Operator expertise: Experience with complex access techniques

Clinical Lessons

For Interventional Cardiologists:

Radial access can serve as alternative route when femoral access is unavailable
Sequential procedural strategy (radial first, then femoral) enables successful treatment in challenging anatomy
Immediate return of femoral pulses after proximal angioplasty confirms successful revascularization
Younger patients with critical limb ischemia require aggressive intervention given elevated amputation risk
Technical versatility and willingness to adapt standard approaches are essential for complex vascular cases

Conclusion

This case demonstrates that when confronted with technical challenges that eliminate standard access routes, innovative procedural strategies can achieve successful revascularization and limb salvage. The hybrid radial-to-femoral approach enabled treatment of critical infrarenal aortic stenosis despite absent femoral pulses, resulting in dramatic clinical improvement and avoiding bilateral amputation.

Key Takeaways:

Radial access serves as effective alternative when femoral access is impossible
Initial balloon angioplasty can restore flow sufficiently to enable secondary access
Younger patients with critical limb ischemia warrant aggressive intervention given elevated amputation risk
Procedural versatility and adaptive planning are essential for complex vascular cases
Successful revascularization provides life-changing functional recovery

This case reinforces the importance of technical innovation in interventional cardiology and the life-changing impact of timely, creative approaches to limb-threatening ischemia.

Learning Points

Critical limb ischemia in patients under 65 carries 24% higher amputation risk
Absent femoral pulses indicate severe proximal disease but don’t preclude intervention
Radial access can reach infrarenal aortic lesions when femoral access unavailable
Restoring flow via balloon angioplasty may create new access options mid-procedure
Hybrid access strategies enable successful treatment in anatomically challenging cases
Early intervention in younger patients provides decades of functional benefit

Patient Perspective

The patient expressed profound relief at avoiding amputation and reported that regaining the ability to walk normally “gave me my life back.” He has returned to all normal activities and remains symptom-free at follow-up.

About Dr. Gyana Ranjan Nayak

Dr. Gyana Ranjan Nayak is an interventional cardiologist in Bhubaneswar specializing in complex vascular and structural heart procedures. His practice focuses on limb-salvage interventions, critical aortic disease management, and advanced cardiovascular care.

Specializations:

Complex peripheral arterial disease interventions
Limb salvage procedures
Aortoiliac revascularization
Structural heart interventions

Correspondence:

Dr. Gyana Ranjan Nayak

Phone: 6371307504

Website: drgyana.com

Dr. Gyana Ranjan Nayak

Interventional Cardiologist