Early outcome of popliteal and tibiopedal retrograde access as a rescue procedure for the endovascular management of complex infrainguinal lesions: a safe and effective technique

Introduction
Retrograde access has been proposed as an alternative technique after failed antegrade recanalization of peripheral arterial disease. This study aims to evaluate the retrograde access for infrainguinal lesions in terms of indications, safety, feasibility, advantages, disadvantages, precautions, and complications.
Patients and methods
This is a prospective study of peripheral arterial disease patients of Rutherford categories 5 and 6 scheduled for endovascular recanalization in whom antegrade recanalization had failed or there was difficulty in re-entering the true lumen distal to the obstruction, with comorbidities precluding open surgical reconstruction. According to the lesion and the distal runoff, the retrograde access was chosen from either popliteal, posterior tibial, or dorsalis pedis arteries.
Results
Overall 29 patients (22 men and seven women) were included in this study. The popliteal access was adopted in 10 patients. All were performed under fluoroscopic guidance, except in the case of one popliteal artery, which was accessed under sonographic guidance. In one patient there was failure to cross the lesion. In two patients, a double-balloon technique was used. Subintimal arterial flossing antegrade retrograde intervention was resorted to in five patients. Nineteen patients had tibiopedal access. All cases were accessed under fluoroscopic guidance except two cases that were done under the US guidance. We successfully accessed the target vessel in 16 patients. The subintimal arterial flossing antegrade retrograde intervention technique was followed in 14 patients.
Conclusion
Early outcome results for retrograde popliteal and tibiopedal access show that it is feasible and safe, with low 30-day morbidity and mortality. This technique expands revascularization options after failed conventional endovascular antegrade approaches.