Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 134-138

Retrograde percutaneous tibial approach for complex infrainguinal occlusions in chronic limb-threatening ischemia after failed antegrade transfemoral approach

Department of Peripheral Vascular Surgery, Apollo Hospitals, Bengaluru, Karnataka, India

Date of Submission22-Oct-2021
Date of Decision30-Nov-2021
Date of Acceptance06-Dec-2021
Date of Web Publication13-Jun-2022

Correspondence Address:
N R Manju Bharath
Department of Peripheral Vascular Surgery, Apollo Hospitals, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_110_21

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Introduction: A significant proportion (20%) of patients with complex infrainguinal arterial occlusions cannot be recanalized using a conventional antegrade endovascular approach. Most of these patients will be poor candidates for open surgical reconstruction owing to the concomitant cardiovascular and pulmonary comorbidities or poor venous conduit. We present our experience using the percutaneous retrograde pedal approach for revascularization of infrainguinal arterial occlusions after failed conventional endovascular options. Materials and Methods: This is a retrospective observational study of all the patients admitted in our center from May 2019 to May 2021 for chronic limb-threatening ischemia with infrainguinal occlusive disease and attempted retrograde tibial approach after failed antegrade transfemoral approach. Procedural success was defined as residual stenosis of <30% after balloon angioplasty or stenting. Limb salvage was defined as freedom from major amputation during the follow-up period. Results: In a total of 20 patients managed with retrograde tibial approach, procedural success was achieved in 18 patients (90%). Limb salvage was achieved in 17 of the 18 patients who had procedural success during the follow-up period. One patient underwent below-knee amputation due to spreading infection. Conclusion: Retrograde tibial approach to recanalize infrainguinal arterial occlusions after failed traditional endovascular methods is safe and effective and should be advocated to avoid more invasive, time-consuming, and high-risk procedures as it offers high technical and procedural success rates with minimal complications.

Keywords: Chronic limb-threatening ischemia, critical limb ischemia, pedal access, peripheral arterial disease, retrograde tibial access, tibiopedal approach

How to cite this article:
Bharath N R, Narasimhan S, Kumar K N, Aggarwal A. Retrograde percutaneous tibial approach for complex infrainguinal occlusions in chronic limb-threatening ischemia after failed antegrade transfemoral approach. Indian J Vasc Endovasc Surg 2022;9:134-8

How to cite this URL:
Bharath N R, Narasimhan S, Kumar K N, Aggarwal A. Retrograde percutaneous tibial approach for complex infrainguinal occlusions in chronic limb-threatening ischemia after failed antegrade transfemoral approach. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Dec 6];9:134-8. Available from:

  Introduction Top

Patients with chronic limb-threatening ischemia (CLTI) require immediate in-line revascularization in addition to optimal medical therapy to alleviate rest pain, stimulate ulcer healing, and minimize the risk of major amputation.[1],[2] Many of these patients present as unsuitable surgical candidates due to high operative risk secondary to cardiovascular and pulmonary comorbidities or poor venous conduit. For these reasons, an endovascular-first approach is being used more frequently in the management of CLTI. The traditional endovascular transfemoral approaches (ipsilateral antegrade and contralateral retrograde) fail to cross the infrainguinal occlusions in approximately 20% of the cases.[3],[4]

Until recently, the inability to cross infrainguinal lesions in an antegrade fashion was accepted as a failure of endovascular therapy and an indication for open surgical reconstruction or medical management in unfit patients. In 1990, Iyer and colleagues described the retrograde tibial approach by cut down to cross the tibial lesion after failed antegrade approach.[5] With the increasing use of ultrasonography (USG) and advancements in fluoroscopic technology, the practice of percutaneous retrograde tibial approach after failed antegrade attempts is being frequently reported in the recent past.[6],[7] We describe our experience with this technique during a 2-year period in 20 patients assessing technical success, procedural success, and limb salvage during a minimum follow-up of 5 months with attending access-site complications.

  Materials and Methods Top

This is a retrospective observational study performed with Institutional Review Board approval at our institution including 20 consecutive patients who were admitted in our institution from May 2019 to May 2021 with CLTI (Rutherford category 4 and 5) and were managed with percutaneous retrograde tibial approach after failed antegrade transfemoral approach to recanalize infrainguinal occlusions.

All posterior tibial artery (PTA) were taken under USG guidance using either the hockey stick or linear array probe (Sonosite Inc, Bothell, Wash) in the longitudinal plane using a 4 cm long, 20G/21G echogenic needle with a single-wall puncture [Figure 1]. Access was secured using either the 7-cm long, 4-Fr radial sheath (Radifocus, Terumo, Tokyo, Japan) or 4-Fr outer diameter and 2.9-Fr inner diameter Micropuncture pedal access set (Cook Medical, Bloomington, Indiana) [Figure 2]. After standard anticoagulation, the infrainguinal occlusions were attempted to cross with either an exchange length 0.014-inch wire (Command ES, Abbott Vascular, Diegem, Belgium) or 0.018-inch wire (V-18 Control Wire, Boston Scientific, Marlborough, MA, USA). In patients where the percutaneous access could not be secured by a 4-Fr sheath due to extensive arterial calcification or subcutaneous tissue fibrosis around the ankle, the lesions were crossed with the help of 0.014-inch support catheters (Rubicon, Boston Scientific or CXI, Cook Medical) or with the help of low-profile tibial balloon catheters of 2-, 2.5-, or 3-mm diameter [Figure 3]. After the successful crossing of the lesion, the exchange length wire was parked high-up in the iliac artery or aorta to facilitate tracking of balloon catheters for angioplasty. In tight occlusions where balloon catheters could not be crossed across the lesion, the retrograde wire was snared and brought out of the femoral access sheath to enable tracking across the lesions. After retrograde balloon angioplasty, the distal part of the accessed artery (distal to the retrograde puncture site) was cannulated in an antegrade fashion, and any adjuvant balloon angioplasty or stenting of the femoropopliteal segment was achieved over the antegrade wire after removing the retrograde wire/sheath [Figure 4]. Pulsatile flows were noted in most of the patients from the retrograde pedal sheath or after removing the balloon [Videos 1 and 2] [Additional file 1] [Additional file 2]. All access sites were sealed with manual compression or endohemostasis (inflation at the level of the puncture site of an angioplasty balloon sized one-to-one to the vessel at a low atmospheric pressure for 2–4 min). All patients received standard postoperative antiplatelet and anticoagulation regimen followed by amputation/debridement of the nonviable tissues. All the three tibial vessels were attempted to be recanalized in all patients using either antegrade or retrograde approach irrespective of the angiosome concept. All patients were regularly followed up for a minimum of 5 months.
Figure 1: (a) Ultrasonography-guided percutaneous access of the anterior tibial artery. (b) 21 G needle for percutaneous access. (c) 20 G needle for percutaneous access

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Figure 2: (a) 4-Fr radial sheath (Radifocus, Terumo) used for tibial access. (b) 4-Fr Micropuncture pedal access set (Cook Medical)

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Figure 3: Posterior tibial artery with 0.014-inch support catheter and 3-mm tibial balloon catheter

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Figure 4: (a) Long segment occlusion of the left Superficial Femoral artery. (b) Lesion being crossed from retrograde tibial access. (c) Completion angiogram after Superficial Femoral artery stenting

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Technical success was defined as intravascular placement of the pedal access sheath/support catheter/balloon catheter within the target vessel as confirmed by retrograde angiogram. Procedural success was defined as successful crossing of the lesion followed by balloon angioplasty/stenting with a residual stenosis of <30% [Figure 5] and [Figure 6]. Limb salvage was defined as freedom from major amputation during the follow-up period. Major amputation was defined as limb loss below or above the knee level.
Figure 5: (a) Long segment occlusion of the right anterior tibial artery. (b) Antegrade wire brought out of the 4-Fr sheath in the anterior tibial artery after successful recanalization from the retrograde approach. (c) Completion angiogram showing good recanalization of the anterior tibial artery

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Figure 6: (a) Long segment occlusion of the left PTA with above-knee origin. (b) Retrograde PTA access with wire crossing the lesion. (c) Lesion successfully crossed with a 2 mm balloon catheter. (d) Balloon angioplasty of the occluded segment. (e) Completion angiogram showing good recanalization of PTA

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  Results Top

The demographics and clinical characteristics of patients are summarized in [Table 1]. Most of the patients in our study were males (80%). The mean age of our patients was 60 years, with a standard deviation of 11 years. Most of the patients presented with tissue loss limited to the forefoot – Rutherford category 5 (80%). Anterior tibial artery including the dorsalis pedis was the most commonly accessed vessel (50%) followed by the PTA, accounting for 40% and peroneal artery (10%). Isolated tibial vessel occlusion was the most commonly found segment in our study (75%), followed by contiguous tibial and popliteal artery occlusion (20%).
Table 1: Patient demographics, clinical category, and treated lesions

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Technical success was achieved in all patients (100%) [Table 2]. Procedural success was achieved in 18 patients (90%). Retrograde crossing of the lesion failed in two patients who had PTA and peroneal occlusions, respectively, despite several attempts and were managed with recanalization of the remaining tibial arteries through antegrade approach. One patient needed concomitant superficial femoral artery (SFA) angioplasty and stenting from the antegrade approach after retrograde balloon angioplasty of the SFA occlusion. One patient had access-site hematoma despite manual compression (peroneal).
Table 2: Technical and procedural success and limb salvage

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All the patients were followed up on a regular basis in the outpatient department and were assessed for symptomatic and clinical improvement and Doppler evaluation. Limb salvage was achieved in 19 patients (95%) during the minimum follow-up period of 5 months. One patient with failed retrograde recanalization of the PTA had heel necrosis and ensuing spreading infection and had to undergo below-knee amputation.

  Discussion Top

CLTI is associated with significant morbidity and mortality, particularly in patients with end-stage renal disease and diabetes mellitus.[1],[2] Aggressive revascularization techniques are indicated in CLTI patients to achieve limb salvage. The global epidemic of CLTI combined with improved endovascular tools and increasing experience of endovascular surgeons has caused a paradigm shift in the treatment of PAD. Endovascular-first approach is increasingly being followed in many centers for the management of patients with CLTI, as most of them are poor surgical candidates due to accompanying comorbidities.

Despite recent advances in endovascular tools and techniques, approximately 20% of the patients with complex infrainguinal occlusive disease cannot be treated with conventional transfemoral approach.[3],[4] The technical hurdle with antegrade approach is failure to penetrate the proximal fibrous cap, which is often hard and complex, preventing the wire from crossing or pushing them quickly into the subadventitial space. The distal fibrotic cap is said to be either very thin or nonexistent.[8] Retrograde tibial approach for revascularization can be attempted through stump wounds in desperate situations also [Figure 7].
Figure 7: The anterior tibial artery access taken from transmetatarsal amputation stump wound in a desperate attempt to revascularize the foot

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In situations where the operators will not be able to cross the lesion through transfemoral antegrade and retrograde tibial access, certain bailout techniques can be applied to disrupt the plaque enough to facilitate the crossing of the lesion. These bailout techniques include double-wire flossing, where two wires with support catheters are manipulated from above and below to disrupt the plaque. The other technique is the double-balloon disruption technique where two balloons are introduced from both above and below and the balloon markers opposed at no more than 2 mm followed by simultaneous inflation of both balloons at low pressure (4–6 atm) to disrupt the atheromatous plaque allowing reentry of the wire in either direction [Figure 8].
Figure 8: Double-balloon disruption technique

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The advantages of retrograde tibial access can be the following:

  1. The tibial vessels with small diameters are very close to the occlusive lesions and may increase the pushability of the wire and support catheter across the lesion
  2. Less likelihood of entering the collaterals/side branches from the retrograde access
  3. The distal part of the occlusion is less fibrotic and concave, yielding to the crossing wire
  4. Less expensive than the routine uses of crossing and reentry devices. It minimizes the amount of operative time, radiation exposure, and the contrast usage.
  5. The procedure can be achieved with local anesthesia/mild sedation and is relatively safe and effective with good technical success.

Similarly, there are potential disadvantages to retrograde tibial access to consider:

  1. Tiny tibial vessels are more prone to vasospasm and thrombus formation
  2. Arterial disruption with resultant thrombosis of the access vessel
  3. Definite learning curve with the need for proficiency in USG imaging.

Taken together, in specific cases of patients with CLTI who are not tibial bypass candidates and who cannot be revascularized with an antegrade approach, selective use of a retrograde tibial approach is safe, technically feasible, and achieves acceptable limb salvage rates.

So far, the literature on retrograde tibial approach for infrainguinal occlusive disease is limited and, to some degree, nonhomogeneous. Walker CM[9] reported the largest series of patients with a high technical success rate of 95% which was comparable to the results achieved in our study. Compared to the results reported by Bazan et al.,[1] we noted that the results for procedural success and limb salvage are similar. There are some limitations to our study including a small study size and lack of randomization. Furthermore, no rigorous imaging follow-up is available, and therefore, no data on patency or target lesion revascularization of the lesions are available.

  Conclusion Top

Although the retrograde tibial approach is a relatively new technique, it is a promising alternative for patients in whom conventional endovascular antegrade techniques have failed. It can significantly reduce the procedural failure rate of conventional endovascular treatments with little added cost or morbidity in patients with CLTI. It is a safe technique with high rates of technical success and minimal complications and should be a part of the armamentarium of all endovascular surgeons.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bazan HA, Le L, Donovan M, Sidhom T, Smith TA, Sternbergh WC 3rd. Retrograde pedal access for patients with critical limb ischemia. J Vasc Surg 2014;60:375-81.  Back to cited text no. 1
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007;45 Suppl S: S5-67.  Back to cited text no. 2
Montero-Baker M, Schmidt A, Bräunlich S, Ulrich M, Thieme M, Biamino G, et al. Retrograde approach for complex popliteal and tibioperoneal occlusions. J Endovasc Ther 2008;15:594-604.  Back to cited text no. 3
Rogers RK, Dattilo PB, Garcia JA, Tsai T, Casserly IP. Retrograde approach to recanalization of complex tibial disease. Catheter Cardiovasc Interv 2011;77:915-25.  Back to cited text no. 4
Iyer SS, Dorros G, Zaitoun R, Lewin RF. Retrograde recanalization of an occluded posterior tibial artery by using a posterior tibial cutdown: Two case reports. Cathet Cardiovasc Diagn 1990;20:251-3.  Back to cited text no. 5
Botti CF Jr., Ansel GM, Silver MJ, Barker BJ, South S. Percutaneous retrograde tibial access in limb salvage. J Endovasc Ther 2003;10:614-8.  Back to cited text no. 6
Spinosa DJ, Leung DA, Harthun NL, Cage DL, Fritz Angle J, Hagspiel KD, et al. Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion. J Vasc Interv Radiol 2003;14:1449-54.  Back to cited text no. 7
Ozawa N. A new understanding of chronic total occlusion from a novel PCI technique that involves a retrograde approach to the right coronary artery via a septal branch and passing of the guidewire to a guiding catheter on the other side of the lesion. Catheter Cardiovasc Interv 2006;68:907-13.  Back to cited text no. 8
Walker C. Pedal access in critical limb ischemia. J Cardiovasc Surg (Torino) 2014;55:225-7.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2]


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