Ultrasound-Guided Retrograde Infrapopliteal Artery Access for Recanalization of Complex Femoral-Popliteal Artery Occlusions

Background: The aim of the study was to review the outcomes of femoral-popliteal artery (FPA) interventions using an ultrasound (US)-guided retrograde infrapopliteal artery access after the failure of an antegrade recanalization. Methods: From Jan 2016 to Jan 2019, 37 patients with chronic total occlusion (CTO) of the FPA underwent ultrasound (US)-guided retrograde infrapopliteal artery access after failure of an antegrade procedure. Treated limbs were classified as Rutherford class 5 or 6 (29.7%) and class 4 (62.2%). Data collected included success rate and time to access using US. Immediate in-hospital and follow-up outcomes were also documented. Results: US-guided retrograde infrapopliteal artery access was successful in 100% of the patients (anterior tibial symbolscript 11, posterior tibial symbolscript 19, Peroneal symbolscript 4, Dorsalis pedis symbolscript 3). Retrograde revascularization was achieved in all 37 patients (100%) using balloon angioplasty (17/37, 45.9%) and additional stent placement (20/37, 54.1%). Ankle-brachial index (ABI) measurements changed from 0.25 +/- 0.1 preinterventionally to 0.75 +/- 0.07 at 1 day postinterventionally (< 0.001). Minor complications occurred in 2/37 patients (5.4%) including one bleeding and vasospasm at the posterior tibial artery, both of which were treated conservatively. No patient experienced access-related thrombosis, aneurysm, compartment syndrome or death. Thirty of 37 (81%) patients completed for at least 12 months of follow-up. None of the successful revascularized patients had major or minor amputations during the follow-up period. Conclusions: US-guided retrograde infrapopliteal artery access is a safe and successful technique, which expands revascularization options after the failure of conventional endovascular antegrade approaches.