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 Table of Contents  
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 3-8

Antegrade revascularization of long-segment femoropopliteal chronic total occlusion: A case report and literature review

Department of Cardiology, AIIMS, Bhubaneswar, Odisha, India

Date of Submission01-Dec-2021
Date of Decision15-Dec-2021
Date of Acceptance27-Dec-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Dr. Debasish Das
Department of Cardiology, AIIMS, Bhubaneswar - 751 019, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartindia.heartindia_101_21

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Although revascularization of a femoropopliteal (CTO) always remains challenging through a retrograde or contralateral crossover approach, we report a case of successful revascularization of a long-segment femoropopliteal CTO through antegrade femoral puncture which stands as the crux of the procedure. In routine peripheral intervention, long-segment femoropopliteal occlusion is usually approached from a contralateral femoral artery or ipsilateral brachial artery, antegrade revascularization of femoropopliteal CTO is not adapted by many in routine practice. Here, we describe the technique and the tips and tricks of antegrade puncture of common femoral artery. We will also discuss the literature review of antegrade technique versus retrograde and crossover technique for revascularization of femoropopliteal CTO which may be useful for budding young interventionists. Our case carries another important learning point about management of popliteal disease where revascularization with a stent is of concern due to high knee joint mobility.

Keywords: Antegrade, femoropopliteal, occlusion, revascularization, total

How to cite this article:
Das D, Kumar A, Mahanta DS, Singh S, Pramanik S. Antegrade revascularization of long-segment femoropopliteal chronic total occlusion: A case report and literature review. Heart India 2022;10:3-8

How to cite this URL:
Das D, Kumar A, Mahanta DS, Singh S, Pramanik S. Antegrade revascularization of long-segment femoropopliteal chronic total occlusion: A case report and literature review. Heart India [serial online] 2022 [cited 2022 Sep 29];10:3-8. Available from: https://www.heartindia.net/text.asp?2022/10/1/3/343064

  Introduction Top

Chronic total occlusions (CTOs) have proximal hard caps and distal soft caps. That is why probing the distal cap which is a soft one retrogradely is always easier than probing the proximal hard cap. Carrying out the femoropopliteal intervention retrogradely is associated with difficulty in popliteal puncture which is deep-seated. It is also difficult to puncture feeble posterior tibial or dorsalis pedis artery due to total or subtotal occlusion of the femoropopliteal segment. Most interventionists revascularize the femoropopliteal segment through contralateral femoral artery access or ipsilateral brachial artery access. Contralateral femoral artery access has an inherent issue of crossing the iliac bifurcation bend from one side to the other with a long peripheral stent and balloon which always require a straight path of the wire for better negotiation. Crossing this iliac bend requires utmost gentleness with slow and steady maneuvering. The issue with the brachial approach is that long catheter course through brachial approach poses an issue as guide catheters cannot reach distal segments of femoropopliteal CTO. Inherent bend at the subclavian innominate junction also creates difficulty in the passage of a long peripheral balloon or stent. We describe the technique of antegrade peripheral puncture and revascularization of a femoropopliteal CTO overcoming the issues of contralateral femoral access, brachial intervention, and retrograde popliteal access. Our case is a teaching point for budding young interventionists to make the femoropopliteal CTO intervention easier through antegrade femoral access.

  Case Top

42-year-old diabetic female presented to the outpatient department with a history of calf claudication for the last 6 months with the gangrenous right foot for which amputation of the great toe and nearby toe was done 1 month back. She revealed no history of thigh or buttock claudication. The patient was treated with multidrug-resistant tuberculosis 1 year back, had the shadow of calcific hilar lymph nodes in chest X-ray PA view. At present, she had no respiratory symptoms with erythrocyte sedimentation rate of 23 mm/h. During the presentation, her blood pressure was 130/80 mm Hg in the right arm supine position, and her heart rate was 84 beats/min. The examination of peripheral pulses revealed absent popliteal, posterior tibial, and dorsalis pedis pulse on the right side with normal peripheral pulses on the left side without any presence of a renal or carotid bruit and symmetrical bilateral radial pulses. Her cardiac system examination was within the normal limit. Her blood sugar was deranged with fasting blood sugar of 176 mg/dl and Post prandial blood sugar (PPBS) of 237 mg/dl with hemoglobin A1C of 8.7% with a deranged lipid profile with low-density lipoprotein of 143 mg/dl. Electrocardiogram and echocardiography of the patient were within the normal limit. Duplex ultrasonography (USG) of the lower limb revealed loss of triphasic flow in anterior tibial and tibioperoneal trunk in the right lower limb suggestive of diffuse disease and complete long-segment occlusion from the distal superficial femoral artery (SFA) up to the mid popliteal artery. Computed tomography (CT) peripheral angiogram also revealed the same [Figure 1] suggestive of long-segment femoropopliteal CTO. We did not adopt the left femoral access for crossover technique because of anticipation of difficulty in the passage of two long stents. We also did not adopt the brachial access as the JR guide may not reach there. Retrograde popliteal access was also not feasible as the mid popliteal segment was harboring the lesion. We thought to revascularize through the antegrade femoral puncture. The patient was positioned under the fluoroscopy in the opposite direction routinely adapted during coronary intervention with the feet end toward the eye of the fluoroscopy and the head end at the foot end of the table so that cine run can acquire the distal limb circulation including the right plantar arch. Under generous local anesthesia (10-ml Xylocaine and 10-ml NS), the right inguinal area anterior to the mid femoral head was infiltrated. Standing on the right side of the leg, Crooks needle was used to puncture the anterior SFA below the femoral head with the back end of the needle facing the right shoulder and the tip facing the foot end [Figure 2]. The short guidewire was introduced up to the mid-SFA, and fluoroscopically, it was confirmed that it was in SFA in spite of profunda femoris artery as it is the profunda femoris into which short guidewire often negotiates, and it requires exchange through a guide into right SFA again. Then, a 6-F introducer sheath was introduced into the right SFA, and sheath injection revealed complete occlusion of the distal SFA. Intravenous heparin 100 U/kg was administered. The CTO of the distal SFA was crossed with angled 0.035 Terumo wire, and the wire was parked in the distal anterior tibial artery. The lesion was dilated with a 5 mm × 60 mm peripheral MUSTANG balloon from the distal popliteal to the proximal SFA with 2–10-atm pressure from the distal to the proximal segment. Postdilatation and after intra-arterial nitroglycerine therapy, the flow was established from distal SFA to anterior tibial and tibioperoneal trunk, but long-segment dissection was noted in the distal SFA and proximal popliteal artery. Then, the lesion was stented with a 7 mm × 100 mm self-expandable (EPIC) stent distally from distal popliteal to distal SFA and another 8 mm × 120 mm self-expandable (E-LUMINEXX) stent overlapping the first stent up to the overlapping the opening point of CTO [Figure 3]. Post percutaneous transluminal angioplasty) distal SFA, proximal, and mid popliteal revealed good flow with well-visualized plantar arch [Figure 4]. Because of diffuse disease of the anterior tibial and tibioperoneal trunk, we decided to put the patient on medical management with single antiplatelet, high-dose statin, arterial blood flow enhancers such as cilostazol and pentoxifylline, and nitroglycerine. The antegrade approach to femoropopliteal intervention makes the total occlusion revascularization easier overcoming the difficulty in retrograde popliteal approach, contralateral crossover, or far enough brachial approach. Although in the popliteal artery, conventional stents may create an issue of stent fracture due to mobility of the knee joint; a highly flexible Supera stent may be desirable in those places to prevent joint movement-induced stent fracture. Because of high joint mobility, we deployed the conventional stent 5 cm before the bony landmark of femoral condyles to avoid excess joint movement-induced stent strut fracture. Postprocedure, we put the patient on clopidogrel 75 mg once daily as in peripheral arterial disease clopidogrel serves better than aspirin, with high dose atorvastatin 80 mg with cilostazol 100 mg, pentoxifylline 400 mg TID with nitroglycerine 2.6 mg BID for diffuse disease in the anterior tibial and tibioperoneal trunk. Her coronary angiogram was within the normal limit. Postprocedure at 1-month follow-up, she was free of limb claudication with healed amputated toe and complete recovery of pregangrenous skin over the right foot and normalization of skin color. The total duration of the procedure was 1 h only. The antegrade approach eases femoropopliteal intervention.
Figure 1: Gangrene of great toe with femoropopliteal chronic total occlusion in computed tomography angiogram

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Figure 2: Antegrade femoral puncture

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Figure 3: Steps of antegrade revascularization

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Figure 4: Good flow from distal superficial femoral artery to plantar arch

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  Discussion Top

Antegrade femoral puncture is often the first step in lower limb intervention or thrombolysis, and the common femoral artery is the site of entry. Selective catheterization of the SFA is done from the common femoral artery. The only local complication with an antegrade puncture is a local hematoma which resolves spontaneously. The larger size of the catheter and use of fibrinolytic therapy increases the risk of hematoma. Although the literature primarily deals with the retrograde puncture, an antegrade femoral puncture is also relatively safe.[1] Antegrade femoral puncture is always challenging than retrograde puncture as observed in the Hamburg access experience in 2009 in which out of 800 femoropopliteal and infrapopliteal interventions, 95% were crossover technique, 2% were trans popliteal, and 3% were antegrade. The antegrade approach makes the femoropopliteal intervention easy. The common indications of the antegrade approach are the presence of bilateral common iliac artery stents, extreme kinking and calcification of pelvic arteries, and surgical aortic prosthesis. In the correct antegrade puncture, the point of entry in Common femoral artery (CFA) should be 1–2 cm proximal to the inguinal crease with the needle at a 45-degree angle to the skin [Figure 5]. Rupp's rule for retrograde femoral puncture is puncture of the common femoral artery at the mid femoral head 1 cm lateral to the medial border [Figure 5]. Puncture more proximal to it may be a high femoral puncture and can result in catastrophic retroperitoneal bleed. Berman described the guidewire-directed antegrade femoral puncture with a guidewire from the contralateral femoral artery as a marker. This “target guidewire technique” overcomes the difficulty in accessing SFA from CFA.[2] The antegrade femoral puncture should not be attempted if there is a significant disease in the common femoral artery or the origin of the SFA which may cause dissection of the artery. An antegrade femoral puncture can be improved with direct SFA puncture with ultrasound guidance using the micropuncture system (Cook Medical, Bloomington, Ind). During ultrasound guidance, the probe is held in transverse orientation, and puncture is done at a 45° angle. However, with an antegrade puncture, the issue of wire preferentially going into the profunda need to be handled. The wire in the profunda femoris artery should be pulled to redirect it in an antegrade orientation to enter into the SFA. USG-guided SFA puncture is helpful in the scarred groin, obesity, and high femoral bifurcations. Kweon et al. described ultrasound antegrade puncture to be safe in a study including 199 antegrade arterial punctures. The sheath size ranged from 4F to 8F. The closure device was deployed in 7% of cases of SFA puncture and 25% of cases of CFA puncture. One minor groin hematoma was noted in the SFA puncture group, two cases in the CFA puncture group required urgent operation, out of which one was a repair of a pseudoaneurysm, and another one was the evacuation of the retroperitoneal hematoma. No thromboembolic complication was noted during the antegrade SFA puncture[3] Nice et al. described the retrograde to the antegrade technique that is following a retrograde puncture, the guidewire is turned and place into the SFA.[4] Narkhede et al. in a study comprising 189 patients with antegrade femoral access for infrainguinal interventions concluded antegrade arterial puncture has a complication rate of 14.28%, out of which ecchymosis is the most common (74.07%) one with groin hematoma being the next most common complication (18.51%) and pseudoaneurysm being the least common complication (0.07%). Age more than 69 years, female sex, 7F sheath size, direct arterial puncture by palpation, and manual compression were associated with a higher incidence of complications.[5] We did the antegrade puncture of CFA by palpation only as bilateral femoral pulses were well palpable, the patient was not obese, the inguinal skin crease could be well delineated and a CT angiogram showed CFA puncture site was free of atherosclerotic involvement. The most common complication noted across all series were a hematoma which occurs in up to 8% of cases and pseudoaneurysm which occurs in up to 4.6% of cases which are managed by USG-guided compression or thrombin injection. Acute arterial occlusion is usually not encountered during antegrade femoral puncture. These antegrade femoral punctures can be safely closed with an angioseal device but the paradox is that those increase the probability of increased local site complications. The only extra effort needed during antegrade access is to redirect the wire into the SFA if at all it traverses into the profunda femoris artery. Bukhtiari[6] concluded from CT angiogram of femoral artery that the common femoral artery is located proximal to the center of the femoral head and the femoral artery bifurcation is located distal to the center of the common femoral head. If the arterial entry is chosen at the level of the center of the femoral head by fluoroscopy, a safe puncture of the common femoral artery can be ensured. With the skin puncture site 1–2 cm proximal to this level, the needle is directed obliquely through the skin, and the common femoral artery is entered at the level of the center of the femoral head. The only disadvantage of CFA access is that it often directs the guidewire to the profunda femoris artery. Therefore, while doing an antegrade SFA access, the direction of the needle should be directed more medially to direct the needle toward SFA. The dictum behind negotiating larger balloons and stents during peripheral intervention is that the Terumo wire over which balloon and stent traverse, should be a straight one which is not possible in crossover technique and brachial approach. Therefore, to make the procedure easy, the antegrade approach is the gold standard for femoropopliteal interventions. It is also difficult to access the popliteal artery in the popliteal fossa and the dorsalis pedis artery in 1st intermetatarsal space with a 4-F sheath. The complications of antegrade puncture can be improved with the use of a micropuncture needle and a 4-F sheath in obese which produces a smaller hematoma due to a small access site opening in the artery. Revascularization through retrograde popliteal access has some inherent drawbacks: it is deep-seated, requires multiple attempts, due to the presence of proximal occlusion, it is often difficult to feel the pulsation, the patient feels more pain despite liberal local anesthetic with deep infiltration. Dorsalis pedis artery access is also difficult as it is difficult to palpate it in the presence of femoropopliteal occlusion, requires a small radial puncture needle, and a 4-F sheath which may not be widely available in the periphery. Schmidt et al.[7] described the indication of retrograde technique only in cases of failed antegrade revascularization. Flush SFA occlusion, occluded stents, wire perforation, and reentry failure are the common causes of antegrade recanalization. Retrograde access as default is performed in supine position with a 21-G needle followed by 4–6 F sheath or dedicated catheter insertion. Ye et al.[8] described the failure rate of antegrade recanalization in 10%–20% of cases (n = 19) where they adopted the retrograde technique. The popliteal artery was accessed medially at the infracondylar plane with the leg in a 60° external rotation with gentle flexion of the knee. Hemostasis at the popliteal access site was achieved by combined intraluminal balloon dilatation and manual compression for 3–5 min. Technical success was achieved in all cases, the majority of the cases had a 4F sheath, there was only one case of popliteal access site occlusion and there were two cases of small local hematoma. The primary patency rate at 6 months was 84%. Singh et al. concluded in cases with flush occlusion or a very short stump at common CFA bifurcation, antegrade recanalization frequently fails due to inability to engage the true ostium of SFA.[9] Shi et al. combined antegrade and retrograde approaches for femoropopliteal CTO interventions. They adopted the retrograde approach when the antegrade approach failed and this dual femoropopliteal approach resulted in successful CTO intervention in 21 patients.[10] The only thing to remember during retrograde puncture technique is the access site popliteal artery occlusion for which good preprocedural anticoagulation is mandatory. Peripheral interventionists most often adapt the crossover technique from the contralateral femoral artery to revascularize the femoropopliteal CTO. If crossing of the hardwires like a long balloon or stent becomes an issue, then they adopt the antegrade approach. The retrograde approach is adapted as a last resort in the event of failure of antegrade access. We in this article advocate the young budding interventionists to adopt the antegrade access for revascularization of femoropopliteal CTOs which eases the delivery of the hardwires across the lesion. Our case is an illustration of femoropopliteal CTO revascularization through antegrade access for young interventionists.
Figure 5: Point of antegrade and retrograde femoral artery puncture

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  Conclusion Top

We describe a rarely practiced art of antegrade puncture of SFA for revascularization of femoropopliteal CTOs which will give the budding young interventionists comfort in maneuvering hardwires across a long-segment CTO. With the improvement of USG-guided direct puncture of SFA with micropuncture needle and 4F sheath, the clumsiness of the short guide wire negotiating into the profunda femoris and occurrence of local hematoma can be avoided. Antegrade femoropopliteal revascularization is promising than conventional crossover and retrograde techniques in achieving a successful outcome in long-segment femoral CTO.

Ethical approval

Institutional Ethical Committee (IEC) approval has been obtained.

Authors' contributions

Debasish Das: Final manuscript Editing

Abhinav Kumar, Dibya Sundar Mahanta, Shashikant Singh: Literature Search

Subash Pramanik: Image Editing.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Blais C. Antegrade puncture of the superficial femoral artery: A pilot project. Can Assoc Radiol J 1993;44:253-6.  Back to cited text no. 1
Berman HL, Katz SG, Tihansky DP. Guided direct antegrade puncture of the superficial femoral artery. AJR 1986;147:632-4.  Back to cited text no. 2
Kweon M, Bhamidipaty V, Holden A, Hill A. Antegrade superficial femoral artery vs. common femoral artery puncture for infrainguinal occlusive disease. J Vasc Interv Radiol 2012;23:1160-4.  Back to cited text no. 3
Nice C, Timmons G, Bartholemew P, Uberoi R. Retrograde vs. antegrade puncture for infra-inguinal angioplasty. Cardiovasc Interv Radiol 2003;26:370-4.  Back to cited text no. 4
Narkhede PS, Kolalu S, Agrawal L, Vivekanand, Srivastava A, Davra D, et al. Incidence and risk factors of complications following antegrade common femoral artery access. Indian J Vasc Endovasc Surg 2017;4:103-6.  Back to cited text no. 5
  [Full text]  
Bukhtiari M. Optimal technique for antegrade femoral artery puncture. Ann King Edward Med Coll 1998;4:8-12.  Back to cited text no. 6
Schmidt A, Bausback Y, Piorkowski M, Werner M, Braunlich S, Ulrich M, et al. Retrograde recanalization technique for use after failed antegrade angioplasty in chronic femoral artery occlusions J Endovasc Ther 2012;19:23-9.  Back to cited text no. 7
Ye M, Zhang H, Huang X, Shi Y, Yao Q, Zhang L, et al. Retrograde popliteal approach for challenging occlusions of the femoral-popliteal arteries. J Vasc Surg 2013;58:84-9.  Back to cited text no. 8
Singh A, Prakash N, Kumar N, Jain AP, Verma R, Krishna V. Retrograde popliteal approach for endovascular revascularization of flush superficial femoral artery chronic total occlusion: A two center experience. Indian J Vasc Endovasc Surg 2021;8:42-7.  Back to cited text no. 9
  [Full text]  
Shi W, Yao Y, Wang W, Yu B, Wang S, Que H, et al. Combined antegrade femoral artery and retrograde popliteal artery recanalization for chronic occlusions of the superficial femoral artery. J Vasc Interv Radiol 2014;25:1363-8.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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