Anterolateral Retrograde Access in Chronic Total Femoropopliteal Occlusions: A Safe and Effective Alternative Approach

Technical Summary: Anterolateral Retrograde Access in Chronic Total Femoropopliteal Occlusions

Problem Statement
The management of chronic total occlusions (CTO) in the femoropopliteal segment remains a significant technical challenge in peripheral artery disease (PAD). While endovascular techniques have evolved, antegrade approaches frequently fail, particularly in complex TASC C-D lesions. When antegrade access fails, standard alternatives present distinct drawbacks:

• Reentry Devices: Devices such as the Outback or Pioneer catheters are effective but expensive, not universally accessible, and carry a reported failure rate of up to 35%. Furthermore, they often necessitate long-segment subintimal angioplasty, which can lead to flow-limiting dissections and require extensive stenting that shortens the healthy distal vascular bed.
• Conventional Transpopliteal Approach: This method requires repositioning the patient from a supine to a prone position, causing discomfort and prolonging procedure time. It is also anatomically limited, as it is not applicable to lesions below Hunter's canal.

Methodology
This retrospective study evaluated the safety and efficacy of an anterolateral retrograde puncture approach as a salvage strategy for femoropopliteal CTOs following failed antegrade intervention.

• Population: The study included 66 patients (mean age 64.5 ± 7.9 years; 87.9% male) treated at Antalya City Hospital between January 2024 and December 2025. All patients had TASC C-D lesions with a mean length of 17.4 ± 6.1 cm.
• Indications for Approach: The anterolateral approach was utilized in cases of antegrade failure due to dissection, extravasation, ambiguous SFA ostium, or short true lumen segments.
• Procedural Technique:
  • Patient Positioning: Patients remained in the standard supine position throughout the procedure, eliminating the need for repositioning.
  • Target Sites: Puncture was performed under fluoroscopic guidance at the P3 segment of the popliteal artery (40 patients) or the tibioperoneal trunk (26 patients).
  • Access: A Seldinger needle was used to puncture the anterolateral region. A 0.35-inch hydrophilic wire was advanced retrogradely toward the proximal femoral artery.
  • Crossing the Lesion: A 4F vertebral catheter was advanced over the wire. For hard, calcified distal caps, the reverse end of the hydrophilic wire or specialized wires (Astato/Helbert) were used to penetrate the cap. Once the cap was penetrated, the catheter was advanced into the occluded segment, and the lesion was crossed.
  • Wire Management: The retrograde wire was either introduced directly into a contralateral femoral sheath or captured using a snare catheter to establish through-and-through access.
  • Intervention: Depending on lesion characteristics, balloon angioplasty alone or self-expandable stent implantation was performed. Stents were deployed to ensure full coverage of the SFA ostium without compromising the common femoral artery or profunda femoris artery.
  • Hemostasis: Bleeding control was achieved via manual compression at the puncture site; no sheaths were left in place for the majority of cases (61/66 patients).

Key Results

• Technical Success: Successful endoluminal recanalization was achieved in 65 of 66 patients (98.5%). Failure occurred in one patient where the lesion could not be crossed either antegradely or retrogradely.
• Procedural Metrics: The mean fluoroscopy time was 19.6 ± 7.6 minutes. Stent implantation was performed in 40 patients, while 25 underwent balloon angioplasty alone.
• Safety and Complications:
  • No perioperative mortality occurred.
  • No extravasation, arteriovenous fistula, aneurysm, or rupture was observed at the puncture site.
  • Manual compression successfully achieved hemostasis in all cases.
  • No adverse clinical or ultrasonographic findings were detected at 1-month and 6-month follow-ups.
• Lesion Characteristics: The approach was effective even in patients with calcified long TASC-D lesions and those with lesions extending to the P1 segment, provided the puncture was distal to the occlusion.

Significance and Claims
The authors posit that the anterolateral puncture approach is a safe and effective alternative for retrograde revascularization in femoropopliteal CTOs, particularly when antegrade approaches fail. The study highlights several specific advantages:

1. Patient Comfort and Efficiency: The technique eliminates the need to reposition the patient (prone to supine), thereby reducing procedure time and discomfort.
2. Technical Ease: Approaching the lesion from the distal cap facilitates easier crossing, often maintaining an intraluminal path and reducing the need for subintimal passage.
3. Vascular Preservation: By favoring intraluminal crossing, the technique reduces collateral vessel loss and minimizes the need for long-segment subintimal angioplasty and excessive stenting, thereby preserving the distal vascular bed.
4. Safety Profile: The ability to achieve hemostasis via simple manual compression, combined with a lack of major access-site complications, supports its clinical applicability.

Limitations and Future Directions
The authors acknowledge the study's limitations, including its retrospective, single-center design and small sample size. They note that operator hand exposure to X-rays was a concern due to fluoroscopic guidance and that obesity may present anatomical challenges requiring longer needles. The paper concludes that while the technique shows high promise, prospective studies with larger cohorts are warranted to assess long-term outcomes and generalizability.