Retrograde Recanalization of a Chronic Total Occlusion of the Posterior Tibial Artery

A 69-year-old male was evaluated for a non-healing ulcer of his right foot. His comorbidities included end-stage renal disease on dialysis, diabetes, coronary artery disease, permanent pacemaker implantation and known peripheral vascular disease with previous left above-the-knee amputation. On examination, he had only a faint distal pulse on the right lower extremity.

Peripheral angiography was performed via the left (contralateral) groin. The superficial femoral artery (SFA) showed no critical stenosis. The deep femoral artery was 100% occluded, the anterior tibial artery was 100% occluded, and the posterior tibial and the peroneal arteries were 100% occluded as well. In the posterior tibial artery, there was a fairly short and calcified segment after the 100% occlusion. Filling to the plantar vessel was present, however, there was delay. Because of the total occlusion of the deep femoral artery, the anterior tibial, posterior tibial and peroneal arteries, the patient was totally dependent on the SFA. Clearly, he was at high risk for above or below the right knee amputation. An attempt was made at revascularization.

A contralateral approach via the left side was first attempted using a .018 Asahi wire (Asahi, Abbott Vascular), but this was unsuccessful. Using a micropuncture, we attained access to the posterior tibial artery using a sheathless system. We went in with a 4 Fr Glide catheter and the .018 Asahi wire (Abbott Vascular). With the Glide catheter support we were able to pass into the popliteal artery into the true lumen. We then exchanged for a Cougar wire (Medtronic, Inc.) and placed a 3.0 Monorail balloon to inflate at the site of the total occlusion. Unable to achieve good patency, we went in with an AngioScore 4.0 x 40 mm balloon (AngioScore, Inc.). There was still inadequate filling; in fact, a large piece of calcification at the site of the total occlusion was observed. The only option was to use a self-expanding stent to salvage this patient’s leg. Thus, a 4.0 mm x 60 mm self-expanding Abbott stent was deployed and then further dilated with the AngioScore balloon, with excellent results: the residual stenosis had decreased from 100% to 0%. There was excellent filling all the way to the foot, including the plantar arteries. The catheter was then removed from the posterior tibial artery and used manual pressure for closure.

This is a case of successful recanalization of a chronic total occlusion (CTO) using a retrograde approach via the posterior tibial artery. CTOs of the lower extremities represent some of the more challenging lesions, are time-consuming and have higher complication rates. Endovascular recanalization of chronically occluded lower-extremity vessels should always be attempted using an antegrade approach first. For those who fail at a concerted effort at antegrade recanalization and have limited surgical options, a retrograde approach is worth the attempt.[1]


1. Montero-Baker M, Schmidt A, Bräunlich S, et al. Retrograde approach for complex popliteal and tibioperoneal occlusions. J Endovasc Ther 2008;15:594–604.


Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI, is an internationally-recognized cardiologist, inventor, educator and author. A diplomate of the American Board of Cardiovascular Diseases and American Board of Interventional Cardiovascular Diseases, Dr. Heuser is one of the early pioneers of angioplasty and is considered one of America’s top cardiologists. Dr. Heuser is currently in practice at the Phoenix Heart Center/Physicians Group of Arizona. He is Chief of Cardiology and Chief of Cardiac Catheterization Laboratory at St. Luke’s Hospital and Medical Center, Phoenix, Arizona, and Clinical Professor of Medicine at the University of Arizona College of Medicine, as well as Director of the Interventional Fellowship Program at the University of Arizona College of Medicine, Phoenix Campus.

With 13 patents granted for different catheters, stents and other medical devices, Dr. Heuser has served as principal investigator to research the safety and/or effectiveness of more than 100 medical devices and 70 pharmaceutical products, and has participated in more than 150 research studies. He has authored over 400 articles, textbooks and medical manuscripts, and is frequently invited to international medical conferences to present the findings of research developed in Phoenix.

Dr. Heuser received his medical degree from the University of Wisconsin School of Medicine in Madison, Wisconsin, and completed his medicine internship and residency, as well as his cardiology fellowship


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