Retrograde Crossing for CLI

By Ajay Mhatre MD, and Richard Heuser MD, FACC FSCAI FACP FESC

Figure 1. Below-knee runoff, right leg. Note the heavily diseased TP trunk with complex appearing plaque.

We present a case of a 78-year-old man with critical limb ischemia of the right foot with a nonhealing ulcer of the right lateral malleolus. We performed diagnostic angiography via the right radial artery. Diagnostic angiography showed an occluded right anterior tibial artery with reconstitution distally, a mildly diseased peroneal artery and a patent posterior tibial artery.

There was moderate to severe complex appearing calcified plaque in the tibial peroneal (TP) trunk. On physical exam, the dorsalis pedis artery could be felt faintly. Angiography of the left foot showed distal anterior tibial artery reconstitution in the foot.

We elected to proceed with intervention of the right TP trunk artery by gaining access via the right posterior tibial artery. This was done due to complex appearing nature of the TP trunk plaque. We felt it may be safer to attempt retrograde crossing first as opposed to antegrade crossing. We thought that there was a risk of possible dissection via the antegrade access route, which would have therefore stopped blood flow to the lower leg.

Editor’s note: See “Retrograde Crossing: When the Front Door Is Locked, Look for Another Way In!” for more details and images from this case.


6 thoughts on “Retrograde Crossing for CLI

  1. In my opinion this is a bad example of how to treat routinely a patient with CLI. Retrograde approach should be the last choice not the first, always.
    This report shows everybody how is possible to complicate a very easy case and to make it too risky for the patient.

    • In general, I do not disagree with the above; however, the aortic iliac junction wa quite tortuous, and we were fairly convinced we would not be able to use the contralateral approach.

  2. Thanks for the nice case..
    Why radial access for a below knee revascularization case? Wouldnt antegrade femoral access be more practical?

    Can you please further explain why retrograde crossing is less likely to dissect?

    • very good remark my young friend
      it is basically because prof Heuser is cardiologist ..
      Logical approach would be- US of the right groin with assessment of flow characteristics to rule out aortoiliac disease and US guided antegrade CFA access.

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