Retrograde Deep Femoral Artery Access as Bailout Technique to Rescue Unexpected Ostial Occlusion during Antegrade Superficial Femoral Artery Recanalization

We report a case of deep femoral artery (DFA) retrograde access for recanalization of an accidental ostial occlusion complicating an antegrade-retrograde superficial femoral artery (SFA) procedure. A 77-year-old man with chronic limb-threatening ischemia of the right lower limb was submitted to a duplex ultrasound that showed a heavy calcified SFA chronic total occlusion. During antegrade and retrograde attempts to cross the SFA obstruction, a control angiogram unexpectedly showed the ostial occlusion of the DFA. Several antegrade attempts to cross the DFA occlusion with various guidewires and catheters were unsuccessfully made. Retrograde access was achieved by direct puncture of the DFA distally to the first perforating artery. With sheathless approach, the occlusion was crossed, the retrograde guidewire was externalized through the femoral sheath, and the balloon angioplasty was then performed antegradely. The SFA recanalization was interrupted because of patient discomfort. The patient had an uncomplicated recovery, with immediate resolution of rest pain probably because of the resolution of the underestimated DFA stenosis. The retrograde DFA access is a useful bailout technique in case of accidental ostial occlusion of the DFA.