CIRSE Annual Congress
GENERAL - CIRSE 2026

September 5-9 | Copenhagen, Denmark

September 5-9 | Copenhagen, Denmark

September 5-9 | Copenhagen, Denmark

September 5-9 | Copenhagen, Denmark

September 5-9 | Copenhagen, Denmark

ProgrammeSneak peeksRetrograde approach including popliteal and pedal access

Retrograde approach including popliteal and pedal access

Three things you will learn in my lecture

  1. How to overcome the 20% failure rate of traditional antegrade crossing by using retrograde access as a highly successful alternative for complex lesions and CTOs.
  2. How to navigate alternative access sites, identify and execute precise punctures in the pedal, tibial, popliteal, or distal SFA when the common femoral artery is unavailable or contraindicated.
  3. How to execute advanced re-entry techniques: Step-by-step guidance on utilizing bidirectional strategies, including the CART technique, Rendezvous maneuvers, and the strategic use of re-entry devices to ensure procedural success.

Dr. Jan P. Goltz
Speaker bio

 

Add this session to your calendar!

Endovascular therapy has become a cornerstone in the treatment of peripheral artery disease (PAD), even in complex lesions. For treatment, it is mandatory to access the arterial vasculature and pass the target lesion with a guidewire. The most often used puncture sites are the ipsi- or contralateral common femoral artery (CFA). However, there are scenarios in which it might be impossible to gain access to the CFA (e.g. anatomical changes following vascular surgery) or in which a puncture might be contraindicated (e.g. infection of the groins). In these cases retrograde access via pedal, tibial, popliteal or the superficial femoral artery (SFA) might represent an alternative access location. The main reason to facilitate a retrograde approach however, is failure of crossing the target lesion via an antegrade approach, be it intra- or subintimally. Reported failure rates for crossing chronic total occlusions (CTOs) range up to 20% of cases. [1]  Failure of antegrade revascularization has been linked to an increased risk for amputation in CLI patients. [2] Tibioperoneal retrograde access has been reported to increase treatment success in these cases. [3] Technical success for retrograde access is reported as high as 96%. [4]

Initially retrograde techniques were used exclusively for revascularization in CLI patients. However, today they are used for revascularization of complex lesions in claudicants as well, with high technical success and an acceptable rate of complications. [1]

One reason for being successful in crossing a lesion from the distal aspect may be reflected by a different plaque morphology of the distal cap being less fibrotic. [1]

Retrograde access techniques may improve crossing success by simply passing a wire from below, by using bidirectional strategies such as CART and rendezvous techniques with dual-channel balloon dilation, or by using a re-entry device (alone or directed to balloon catheter from the opposite access).

A recent meta-analysis reported complications like perforation (2.1%), flow limiting dissection (0.6%), distal embolization (0.1%) and local haematoma (1.3%) in an acceptable small proportion of patients. [4]

Besides retrograde access to tibioperoneal vessels, the distal SFA, popliteal artery or the occluded (target) lesion itself might be used for retrograde puncture after a failed antegrade approach. [5,6]  Also, retrograde revascularization of an occluded tibial artery by antegrade crossing of a patent opposite tibial artery and the pedal-plantar arteries has been described as an alternative retrograde alternative, however without an additional retrograde puncture but with a lower percentage of technical success. [7]

Indications, techniques, results and complications of retrograde access – based revascularizations after a failed antegrade attempt will be discussed.

Jan P. Goltz, MD

SANA Hospital Lübeck, DE

Jan P. Goltz, MD, is a Professor of Radiology at the University of Lübeck and the Head of the Institute for Diagnostic and Interventional Radiology/Neuroradiology at SANA Hospital Lübeck, Germany. As a Fellow of CIRSE and an EBIR-ES certified specialist, he is a leading expert in interventional radiology and vascular medicine, currently serving as Deputy Director of the SANA Heart & Vascular Centre.. His extensive academic and clinical career across Germany and South Africa focuses on advancing minimally invasive image-guided therapies and complex endovascular interventions.

References

  1. Schmidt A, Bausback Y, Piorkowski M et al. Retrograde Tibioperoneal Access for Complex Infrainguinal Occlusions: Short- and Long-Term Outcomes of 554 Endovascular Interventions. JACC Cardiovasc Interv. 2019 Sep;12(17):1714-1726.
  2. Singh GD, Armstrong EJ, Laird JR, et al. Primary retrograde tibio-pedal approach. Cardiovasc Revasc Med. 2019;20(10):879–883.
  3. Montero-Baker M, Schmidt A, Bräunlich S et al. Retrograde approach for complex popliteal and tibioperoneal occlusions. J Endovasc Ther. 2008 Oct;15(5):594-604.
  4. Giannopoulos S, Palena LM, Armstrong EJ. Technical Success and Complication Rates of Retrograde Arterial Access for Endovascular Therapy for Critical Limb Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2021 Feb;61(2):270-279.
  5. Trenkler C, Blessing E, Jehn A et al. Retrospective Case Control Matched Comparison of the Antegrade Versus Retrograde Strategy After Antegrade Recanalisation Failure in Complex de novo Femoropopliteal Occlusive Lesions. Eur J Vasc Endovasc Surg. 2024 May;67(5):799-808
  6. Winther B, Schmidt A, Wilz S et al. Retrograde Access via Direct Puncture of the Occluded Segment in Complex Femoropopliteal Chronic Total Occlusions. JACC Cardiovasc Interv. 2026 Jan 12;19(1):115-117.
  7. Stahlberg E, Stroth A, Haenel A et al. Retrograde Revascularization of Tibial Arteries in Patients with Critical Limb Ischemia: Plantar-Arch Versus Transpedal Approach. J Endovasc Ther. 2022 Apr;29(2):181-192.