Popliteal arterial access

Abstract

Among patients with peripheral artery disease (PAD), the femoropopliteal (FP) segment is the most commonly affected, with >50 % of all peripheral artery occlusions involving the superficial femoral artery (SFA) and popliteal arteries. Disease in this segment often involves long, diffuse lesions and/or long chronic total occlusions (CTO) that tend to be heavily calcified. Most of these lesions are TASC (Trans-Atlantic Inter-Society Consensus) II C and D lesions, in which surgery is still preferentially recommended. Current endovascular therapies targeting long or even total occlusions of the entire SFA into the proximal segment of the popliteal artery (PA) are now feasible in more than 90 % of cases. Not infrequently, the CTO extends to the SFA ostium, making antegrade crossing difficult, if not impossible. Histologically, the proximal cap of an occlusion contains the greatest concentration of calcium and collagen and presents a convex shape which frequently deflects the wire to the subintimal space, while the distal cap is softer and concave, facilitating the entry of a wire from the retrograde approach. Retrograde popliteal arterial access is indicated when there is no ostial SFA “nub” or “stump” (chronic “flush” ostial SFA occlusion), difficult antegrade ipsilateral femoral access (i.e., morbid obesity, scarring, prior bypass grafting), difficult