Usefulness of trans-occluded pedal arch access to recanalize chronic total occlusion of the tibial artery in patients with chronic limb-threatening ischemia

Background Endovascular therapy (EVT) is often used for revascularization in patients with chronic limb-threatening ischemia. However, achieving revascularization is challenging. In instances where the guidewire cannot pass through the lesion using an antegrade approach, it is common to incorporate a retrograde approach, such as a trans-collateral approach or distal puncture. However, adding a retrograde approach to cases without below-the-ankle runoff is difficult. In such cases, we have successfully treated patients by directly puncturing the occluded pedal arch under extravascular ultrasound (EVUS) guidance and achieved a pull-through. We herein introduced the method and named it as the Trans-Occluded Pedal arch Access to recanaliZe chronic total occlusion of the tibial artery (TOPAZ) technique. Case Presentation A man in his 60s with Rutherford class 6 peripheral artery disease presented with resting pain and gangrene in the left foot. Angiography revealed chronic total occlusion from the proximal posterior tibial artery to the plantar artery. EVT was selected; however, the conventional approach failed. Switching to a trans-pedal approach, we faced challenges, leading to a puncture of the occluded common plantar region using EVUS guidance. Successful revascularization was achieved without calcaneal branch loss. The patient's resting pain was alleviated, and his wounds healed 6 months post-EVT. Conclusions This case shows the efficacy of the novel TOPAZ technique in addressing difficulties in revascularization when conventional approaches, such as retrograde methods, fail.