“Yes, you can always cross”: Simplified Retrograde Access for Superficial Femoral Artery Occlusions

Access techniques and approaches in complex peripheral procedures opened Wednesday’s program in Main Arena 1, with chronic total occlusions (CTOs), entry tips, and crossing challenges all taking center stage. In his presentation, Grzegorz Halena, MD, from the Medical University of Gdansk, Poland, tackled simplified retrograde access for superficial femoral artery (SFA) occlusions, taking the position that they are always possible to cross.

What are the primary challenges in managing SFA occlusions?

The first and foremost is successful crossing the occlusion. Sometimes long CTOs are surprisingly easy to cross, while crossing shorter occlusions proves to be time-consuming and challenging. In either case the operator should have a plan in mind when antegrade crossing fails.

Retrograde access is often seen as a secondary approach. What led you to focus on simplifying this technique, and how does it change the paradigm for treating SFA occlusions?

Retrograde access should always be a secondary approach. My technique has evolved over the years. I remember how impressed I was when I saw live cases performed here in Leipzig, probably more than 10 years ago. Everybody, including me, has moved in the same direction, which is to minimize the diameter of retrograde access. Sheathless techniques are the way to go.

Retrograde access can pose risks such as vessel injury or infection. How does your simplified technique mitigate these risks?

Everybody should develop their own way using the tools available on the shelf. Using the same guidewires, support catheters, and imaging (X-ray in my case) leads to a repeatable and safe technique. Tactile feedback can only be developed when using this technique on a regular basis. It is never merely an act of ‘pushing’.

Computed tomography angiography analysis (when available) is also very helpful. Whenever I see a calcified occlusion, I am assessing vessels distal to the occlusion, looking for potential retrograde access sites. And I always prep the whole limb. Those 2 elements remove the initial ‘mental block’ that simply means that I am ready to do it rather sooner than later. Poking from above for another 15 minutes can be daunting and pointless if you see no progress. I have never seen infection of a vessel injury.

Your presentation title is intriguing—do you really mean ‘yes, you can always cross,’ and how does this mindset influence procedural success?

Actually, I remember a very similar title from another conference a couple of years ago. Yet still some operators are hesitant to embrace the technique described in detail by Leipzig group years ago. An inability to cross should not determine the fate of the patient, because yes, you can always cross!

It is really a small evolution of the local Leipzig technique. Attend my lecture, and maybe this time I will be able convince you that it is easy!

For interventionalists new to retrograde techniques, how steep is the learning curve for your simplified approach?

It might be mentally easier for vascular surgeons to embrace this approach. The beauty of the procedure is that in the vast majority of cases I only use a standard armamentarium of tools: nothing fancy.

The only valid point is crossing. It does not matter whether you achieve it from above or below. If you are comfortable with re-entry devices and your success rate is 99%, stick with the technique you are comfortable with.

Are there clinical studies or data that support the efficacy and safety of your approach? How does it compare to standard antegrade techniques in terms of outcomes?

There are plenty of data coming from Europe, USA and Japan. You should of course expect worse patency in patients where retrograde access was used, but it has nothing to do with the technique. Long calcified lesions that are difficult to cross will result in more re-occlusions than ‘easier’ lesions.

What’s next?

Despite the rapid development of specialty guidewires and new re-entry devices, retrograde access is here to stay. Do not hesitate to use it.

I am hoping to see improvement in crossing rates in future trials. With the widespread use of retrograde access or re-entry devices it should really be at least 95%. Some recent publications present much worse crossing rates.

For complex SFA lesions you can’t always guarantee good long-term patency rates. Every journey begins with a single step. Here, that first step is crossing.