Keywords
wire rendezvous - retrograde access - hybrid techniques
Introduction
Long-segment infrainguinal arterial occlusions often pose considerable challenges
to endovascular revascularization. In cases where standard antegrade approaches fail,
retrograde and combined antegrade–retrograde (“rendezvous”) techniques are increasingly
utilized to achieve successful crossing and recanalization. This report describes
a successful hybrid recanalization using mid-superficial femoral artery (SFA) puncture
and rendezvous technique, along with a concise review of evolving hybrid strategies
in the management of complex peripheral arterial occlusions.
Case Report
An 85-year-old male patient presented with nonhealing ulcer in the hind foot since
1 month (Rutherford category 5 ischemia). The patient had significant cardiovascular
risk factors, including a 20-year history of smoking, chronic alcoholism, poorly controlled
hypertension, and diabetes mellitus. The preprocedure ankle-brachial index (ABI) was
0.35. Computed tomography angiogram confirmed a long-segment occlusion of the right
superficial femoral artery (SFA) from the origin and P1 segment of popliteal artery.
The P2 popliteal was reformed by collaterals ([Fig. 1]).
Fig. 1 (A) Initial external iliac artery angiogram demonstrating complete occlusion of superficial
femoral artery (SFA) from the ostium (arrow) with hypertrophied profunda and collaterals
(asterisk). (B) Extensive collaterals in the thigh region (arrows). (C) Reformation of the P2 popliteal artery by collaterals and single anterior tibial
artery (ATA) runoff (arrows).
A retrograde puncture of the contralateral common femoral artery was performed and
a crossover sheath placed. Sheath angiogram revealed complete occlusion of the right
SFA at the origin with hypertrophied collaterals. The SFA stump was not visible. Multiple
attempts at antegrade crossing using standard guidewires failed, with the wire entering
a subintimal plane at the SFA ostium without any advancement or successful reentry
distally.
The P2, P3 popliteal was assessed for retrograde access, but the vessel was heavily
calcified and markedly attenuated. Hence, the plan was abandoned and a combined antegrade-retrograde
approach was then pursued.
A mid-SFA puncture was performed under ultrasound guidance and an 18G needle was punctured
and 035 J tip Terumo guidewire was passed retrogradely, which could cross the SFA
ostium with successful luminal reentry in the right external iliac artery.
The retrograde wire was successfully snared from the antegrade sheath in the right
external iliac artery. After snaring, the retrograde needle was removed carefully,
maintaining guidewire position. Antegrade insertion of 4f TERUMO Glide catheter was
done and externalized guidewire was carefully withdrawn and reversed to cross the
needle puncture site into the P2 popliteal artery. After confirming the intraluminal
position of the catheter in the P2 popliteal artery, antegrade balloon angioplasty
was performed ([Fig. 2]).
Fig. 2 (A) An 18G needle puncture of the mid-superficial femoral artery (SFA) (arrow) with
retrograde 035 wire reaching the antegrade wire subintimally (asterisk). (B) Reentry in the right distal external iliac artery (arrow) with snaring from the
contralateral crossover sheath (asterisk). (C) Antegrade balloon angioplasty of SFA (arrow).
Completion angiography demonstrated excellent luminal patency without residual stenosis
or distal embolization. No flow-limiting lesions were noted. There was no extravasation
from the needle puncture site ([Fig. 3]). Postprocedure, the patient had a palpable distal pulse and ABI improved to 0.82.
He was discharged on dual-antiplatelet therapy.
Fig. 3 Final angiogram demonstrating complete recanalization of the proximal superficial
femoral artery (SFA) (A), mid and distal SFA (B), and P1 popliteal artery (C), with patent single anterior tibial artery (ATA) runoff (D, arrows).
At 3-month follow up, there was progressive healing of hind foot ulcer, with complete
healing of the ulcer at 6 months.
Discussion
Combined antegrade and retrograde recanalization strategies have become increasingly
important for treating long-segment chronic total occlusions (CTOs) in infrainguinal
and infrapopliteal vessels, especially when standard antegrade approaches fail. Retrograde
techniques can significantly increase the success rates in difficult cases by providing
an alternative pathway for wire passage and lumen reentry.[1]
Retrograde puncture options include distal SFA, popliteal artery, tibial arteries,
and pedal arteries. The choice depends on the lesion location, vessel quality, and
available access sites.[2] Retrograde access is typically performed under fluoroscopic, duplex ultrasound,
or roadmap guidance, and techniques may include direct puncture or open surgical cutdown.
When combined with antegrade techniques, retrograde access can facilitate successful
reentry into the true lumen, significantly improve procedural success, reduce procedural
time, allow completion of the procedure in a controlled manner, and decrease the need
for surgical bypass in complex infrainguinal occlusions.
The following are the specialized techniques for combined antegrade-retrograde recanalization:
SAFARI technique (subintimal arterial flossing with antegrade-retrograde intervention):
Introduced for infrapopliteal CTOs, SAFARI involves gaining both antegrade and retrograde
access into the subintimal space.[3] A retrograde wire is advanced to meet the antegrade wire, often utilizing snaring
techniques for wire externalization.
CART technique (controlled antegrade and retrograde tracking): Primarily developed
for coronary CTOs, CART involves antegrade balloon inflation within the occluded segment
to enlarge the subintimal space, facilitating retrograde wire passage into the true
lumen.[4]
Reverse CART: A modification of the CART technique where the retrograde wire creates
the initial subintimal space, followed by antegrade balloon dilatation to enable wire
passage.
PIERCE technique (percutaneous direct needle puncture of calcified plaque): Useful
when heavily calcified occlusions resist wire or device passage. A needle is used
to directly puncture the calcified plaque or subintimal channel to allow device advancement
or facilitate rendezvous.
WIRE Rendezvous technique: A straightforward method where a retrograde wire is inserted
into the subintimal space and is then captured antegrade, often using a snare.[5] Particularly effective when retrograde access into the true lumen is difficult.
[Fig. 4] demonstrates schematic diagrams of SAFARI, CART, and PIERCE techniques.
Fig. 4 Schematic illustrations of SAFARI (subintimal arterial flossing with antegrade-retrograde
intervention), CART (controlled antegrade and retrograde tracking), and PIERCE (percutaneous
direct needle puncture of calcified plaque) techniques.
In our case, the mid-SFA puncture combined with the wire rendezvous technique provided
a simple, effective solution for long-segment SFA occlusion recanalization without
the need for tibial access or complex reentry devices.
Conclusion
The combined antegrade-retrograde wire rendezvous technique is a valuable tool in
the endovascular treatment of complex, long-segment SFA occlusions. Familiarity with
combined access strategies and hybrid techniques such as SAFARI, CART, reverse CART,
PIERCE, and wire rendezvous can significantly enhance technical success rates and
optimize patient outcomes in peripheral endovascular interventions.
