Retrograde Popliteal Approach For Endovascular Revascularization Of Flush Superficial Femoral Artery Chronic Total Occlusion: A Two-Center Experience

Introduction: Chronic total occlusions (CTO) of the superficial femoral artery (SFA) are generally managed by an endovascular retrograde contralateral "crossover" or ipsilateral antegrade common femoral artery (CFA) approach. In cases with flush occlusion or a very short SFA stump at common CFA bifurcation, antegrade recanalization frequently fails due to an inability to engage the true ostium of the SFA. The purpose of this study was to evaluate the efficacy and safety of retrograde popliteal approach for endovascular revascularization of flush SFA CTO. Materials and Methods: We retrospectively investigated 18 patients (14 males and 4 females, mean age 61 +/- 14 years) with flush SFA CTO undergoing retrograde popliteal artery (PA) revascularization at two endovascular centers in North India between January 2017 and December 2018. All the patients had critical limb ischemia (CLI) and flush SFA CTO with ostial involvement. Hemostasis was achieved by the manual compression only. Study endpoints were technical success rate, puncture site complications, and limb salvage. Results: CLI with Rutherford category 5 dominated the clinical presentation (56%) with most of the patients presenting late after disease onset. Majority were Trans-Atlantic Inter-Society Consensus-C (72%) chronic SFA occlusions (mean lesion length 185 +/- 52 mm). Doppler-guided popliteal puncture and sheath placement were successful in 100%. Technical success rate of retrograde revascularization was 83%. Intraluminal recanalization was possible in 56% from the popliteal access, and subintimal recanalization was done in 28%. There was no major access site-related complication or mortality in the follow-up period. The primary patency rates at 6 months and 1 year postintervention were 93% and 80%, respectively. Conclusions: Retrograde PA approach under Doppler guidance was effective in terms of technical success rate of popliteal puncture as well as retrograde revascularization of flush SFA CTO. The approach was safe with no major access site complications.