PURPOSE: To describe a novel technique for achieving reliable hemostasis after retrograde popliteal or proximal below-the-knee (BTK) arterial access, particularly in larger-profile interventions, through trans-sheath injection of a hemostatic matrix with thrombin to seal the percutaneous tract. TECHNIQUE: Following completion of the endovascular procedure, a guidewire is advanced from the antegrade femoral access across the retrograde puncture site, and an appropriately sized balloon catheter is positioned at this level. The retrograde sheath is gently withdrawn under aspiration until extraluminal placement is confirmed. The balloon is then inflated, and the hemostatic matrix with thrombin is injected through the sheath lumen to occlude the tract. After 3 minutes, angiography is performed to ensure complete hemostasis, vessel integrity, and preserved distal flow. RESULTS: The method was applied in 21 consecutive cases (15 popliteal, 6 BTK) requiring access site ≥ 5F. Primary technical success was 95.2% (20/21). In 1 patient, an additional 5 minutes of balloon compression was required. No secondary complications, including pseudoaneurysm, thrombosis, infection, or distal embolization, were observed during 30-day follow-up. CONCLUSION: This closure strategy using trans-sheath delivery of hemostatic matrix with thrombin is feasible, safe, and reproducible, offering effective hemostasis after increased-bore retrograde popliteal or proximal BTK accesses.Clinical ImpactThis technique provides a reliable and reproducible solution for achieving hemostasis following retrograde popliteal and proximal below-the-knee arterial access, particularly in procedures requiring larger sheath sizes. By combining balloon occlusion with trans-sheath delivery of a hemostatic matrix containing thrombin, it minimizes the risk of access-site complications such as bleeding, pseudoaneurysm formation, and distal embolization. This approach may expand the safe use of retrograde access in complex peripheral interventions, reduce the need for prolonged manual compression or surgical repair, and improve overall procedural efficiency and patient outcomes.
Lobato et al. (Sun,) studied this question.