Safety and Efficacy of the Retrograde Pedal Approach for Lower Extremity Revascularization in Chronic Critical Limb-threatening Ischemia

Objective: The aim of this study was to evaluate the technical success, procedural safety, and short-term clinical outcomes of the retrograde pedal approach in patients with chronic limb-threatening ischemia following unsuccessful antegrade revascularization. Methods: This retrospective study included 68 consecutive patients (mean age, 68.5±8.2 years; 70.6% male) presenting with severe chronic limb-threatening ischemia (Rutherford categories 4–6). All underwent an attempted retrograde pedal or anterior tibial artery (ATA) access after initial antegrade or contralateral crossover approaches proved unfeasible. Ultrasound-guided access was performed via the posterior tibial artery (66.2%) or ATA (33.8%) following failure of conventional routes. Primary endpoints were access success, technical success, clinical success (freedom from major amputation for at least 6 months), and complication rates. Results: Successful retrograde puncture and target vessel access were achieved in 64 patients (94.1%). Among these, lesion crossing and luminal patency were accomplished in all cases, yielding a 94.1% technical success rate. Interventions included balloon angioplasty (82.3%) and stenting (11.7%), notably including five cases of proximal iliac stenting through distal access. No major access-site complications occurred; minor complications (16.2%) were managed conservatively. Clinical success and symptom improvement were achieved in 88.2% (60/68) of the entire patient cohort. During follow-up, the major amputation rate was 10.3% (7/68), and the mortality rate was 2.9% (2/68). Conclusion: The retrograde pedal approach represents a safe, versatile, and highly effective bailout strategy for complex lower extremity chronic total occlusions. It provides excellent technical and limb salvage rates with minimal access-site complications when conventional antegrade revascularization strategies prove unsuccessful.