# Dual Retrograde Access to Preserve the Popliteal Bifurcation in a Complex Femoropopliteal Occlusion

Raphaël Coscas, Reda Jerrari, Jérémie Jayet

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Raphaël Coscas, Reda Jerrari, Jérémie Jayet. Dual Retrograde Access to Preserve the Popliteal Bifurcation in a Complex Femoropopliteal Occlusion. European Journal of Vascular and Endovascular Surgery, 2024, 68 (2), 10.1016/j.ejvs.2024.06.016. hal-04724505

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Submitted on 18 Oct 2024

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# Dual Retrograde Access to Preserve the Popliteal Bifurcation in a Complex Femoropopliteal Occlusion

Raphaël Coscas<sup>a,b,*</sup>, Reda Ferrari<sup>a,b</sup>, Jérémie Jayet<sup>a,b</sup>

## INTRODUCTION

Endovascular recanalisation of popliteal lesions ending close to the tibial artery ostia may compromise the distal vasculature. Various angioplasty techniques have been described but always involve at least one femoral access. The single primary retrograde access technique, also called tibiopedal arterial minimally invasive retrograde revascularisation (TAMI), can be used to treat challenging femoropopliteal lesions without any anterograde access. In this case, a dual TAMI technique was used to preserve the popliteal bifurcation.

## TECHNIQUE

A 66 year old patient had ischaemic rest pain of the right lower limb. Duplex scan and computed tomography angiography revealed a femoropopliteal occlusion ending at the level of the popliteal bifurcation (Fig. 1A). The femoral approach was considered to be risky because of calcified common femoral arteries and ostial superficial femoral artery lesions. As the posterior tibial and dorsalis pedis arteries were patent at the ankle, a dual TAMI technique was planned. In a hybrid room,

both the posterior tibial and dorsalis pedis arteries were punctured under ultrasound guidance using a 21 gauge needle (Cook, Bloomington, IN, USA). A 5 F Glidesheath Slender (Terumo, Tokyo, Japan) was introduced in each artery (Fig. 1B). V18 (Boston Scientific, Marlborough, MA, USA) and Halberd (Asahi, Aichi, Japan) wires with CXI support catheters (Cook, Bloomington, IN, USA) were used for recanalisation. Kissing balloon angioplasty of the popliteal bifurcation using two 4 × 80 mm Passeo 18 balloons (Biotronik, Bülach, Switzerland) was carried out, followed by a femoropopliteal angioplasty using a 6 × 250 mm Armada balloon (Abbott Vascular, Santa Rosa, CA, USA). Drug coated balloons were then inflated without stenting. Completion angiography showed a satisfactory result with preservation of the popliteal bifurcation (Fig. 2). Haemostasis was obtained by manual compression. At three months, duplex scan examination found patent popliteal and tibial vessels.

## CONCLUSION

A dual TAMI technique can be carried out to preserve the popliteal bifurcation without requiring any anterograde access.

<figure><img src="image_2.png" /><figcaption>**Figure 1.** (A) Pre-operative computed tomography angiography (3D reconstruction) showing occlusion of the popliteal artery ending at the level of the bifurcation (arrows). (B) A dual tibiopedal arterial minimally invasive retrograde revascularisation technique was carried out under local anaesthesia with sedation using posterior tibial and dorsalis pedal artery retrograde access with a 5 F Glidesheath Slender (Terumo, Tokyo, Japan).</figcaption></figure>

<figure><img src="image_3.png" /></figure>

<figure><img src="image_4.png" /><figcaption>**Figure 2.** Retrograde crossing of the occlusion was carried out, followed by (A) a kissing balloon technique with two 4 × 80 mm Passeo 18 balloons (Biotronik, Bülach, Switzerland), which allowed the popliteal bifurcation to open and (B) preserve both the anterior tibial artery and the tibioperoneal trunk ostia without the need for any femoral access.</figcaption></figure>

<footnote><sup>a</sup>Department of Vascular Surgery, Ambroise Paré University Hospital, Boulogne-Billancourt, France</footnote>

<footnote><sup>b</sup>UMR 1018, Inserm-Paris 11 CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, Villejuif, France</footnote>

<footnote>* Corresponding author. Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92104 Boulogne-Billancourt, France.</footnote>

<footnote>E-mail address: rcoscas@gmail.com (Raphaël Coscas).</footnote>

<footnote>1078-5884/© 2024 The Author(s). Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).</footnote>

<footnote>https://doi.org/10.1016/j.ejvs.2024.06.016</footnote>