Retrograde pedal access to facilitate intraluminal recanalization in complex infrainguinal chronic total occlusions

Background: This study aimed to assess the feasibility, safety, and clinical performance of retrograde pedal access to facilitate intraluminal crossing in complex infrainguinal chronic total occlusions in patients with advanced peripheral artery disease. Methods: In this retrospective, single-centre analysis, 33 patients undergoing endovascular revascularization for complex peripheral arterial chronic total occlusions between August 2021 and October 2024 were evaluated. Retrograde pedal access was performed when intraluminal crossing could not be achieved using antegrade or contralateral femoral approaches. The primary endpoint was technical success, defined as successful intraluminal crossing. Secondary endpoints included procedural complications, freedom from clinically driven target lesion revascularisation, longitudinal changes in Rutherford classification, wound healing, limb salvage and all-cause mortality. Results: Successful intraluminal crossing via retrograde pedal access was achieved in 30 patients (90.9%). The posterior tibial artery (39.4%) and anterior tibial artery (36.4%) were the most commonly utilized access sites. Among the 30 patients who underwent definitive endovascular treatment after successful intraluminal crossing, the most frequent complication was flow-limiting dissection, occurring in five patients (16.7%); no cases of perforation, distal embolization, pseudoaneurysm, arteriovenous fistula, or procedure-related death were recorded. Kaplan-Meier estimated freedom from clinically driven target lesion revascularization was 96.7% at 12 months and 75.5% at 24 months. No major amputations occurred, and all patients presenting with tissue loss achieved complete wound healing, with or without minor amputation. Conclusion: Retrograde pedal access represents a safe and effective approach for achieving intraluminal crossing in complex peripheral chronic total occlusions, particularly among patients with chronic limb-threatening ischemia. The high rate of technical success and favorable limb-related outcomes support its role as an integral component of modern endovascular revascularization strategies.