Balloon-Assisted Retrograde Puncture of Distal Vessels in Patients Unsuitable for a Conventional Transpedal Approach

Purpose: To describe a novel bailout technique to approach below-the-knee chronic total occlusions after a failed bidirectional recanalization attempt using the plantar loop maneuver in patients who are poor candidates for a retrograde puncture. Technique: After a failure of recanalization of the opposite tibial artery using the plantar loop maneuver, an assisted direct retrograde transpedal approach can be performed regardless of poor vessel caliber or even arterial occlusion. After crossing the plantar arch, a low profile angioplasty balloon is used as a landmark for the pedal puncture and to give guidance for the wire advancement from the new access. Conclusion: A balloon-assisted retrograde transpedal approach may be considered for below-the-knee recanalization after standard plantar loop technique failure in patients who are not candidates for conventional retrograde puncture.