Author Credentials

Ahmed Amro, MD, Shahed Elhamdani, MS2, Alaa Gabi, MD, Haytham Aljoudi, MD, Mehiar El-Hamdani, MD, FACC, FSCAI


CLI, Critical limb ischemia, PAD, pedal access, retrograde access, Rutherford stage IV-VI, retroagrade as primary approach, limb salvage


Cardiology | Other Analytical, Diagnostic and Therapeutic Techniques and Equipment | Surgical Procedures, Operative | Therapeutics



We are presenting three cases (out of similar several cases) where tibio-pedal approach was performed as an initial primary approach for limb salvage in patients with CLI secondary to Infra-popliteal (IP) disease. We consider this approach to be a necessary evolution in endovascular intervention.


Retrograde pedal access is safe, feasible with high technical success rate and a relatively low procedural complication rate, with low 30 days mortality and low rate of major adverse cardiac events. Freedom from major adverse limb events and limb salvage are both high at 1 year follow up. It allows quick therapy and short procedure time with less observation time in the hospital. A retrograde approach utilizing pedal access improves the crossing success of lesions as well as facilitates the use of some atherectomy devices to remove large plaque burden and modify the compliance of severely calcified infra-popliteal vessels. Using the retrograde approach will minimize the classic complications of the antegrade femoral approach.


Retrograde tibio-pedal arterial access, as an initial primary approach for endovascular intervention in CLI patients confined to IP vessels, is an effective, safe, and feasible approach with a high technical success rate and a relatively low procedural complication rate.