Background: The objective of this study was to evaluate the long-term safety and efficacy of endovascular therapy (EVT) in complex aortoiliac occlusive disease (AIOD) treated with aortic bifurcation reconstruction using the kissing stent or Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique. Methods: This retrospective single-center study included 201 patients (79.6% ASA stage ≥3) with symptomatic TASC-II C/D AIOD who underwent EVT between 2010 and 2019. Endpoints included technical success and procedural complications. Outcomes assessed over a 5-year follow-up included primary and secondary patency rates, major limb amputation, and survival. Kaplan-Meier (KM) estimates and Cox regression were used for analysis. Results: The cohort had a mean age of 61.9 ± 9.7 years, included 61 female patients (30.3%), and showed a low prevalence of obesity (body mass index >30: 7.5%), while cardiovascular risk factors were highly prevalent, including hypertension in 81.1% and hyperlipidemia in 79.6% of patients. Technical success was achieved in 96.0% (193/201), with 87.1% (175/201) of patients treated with kissing stents and 12.9% (26/201) with the CERAB technique. Overall, major complications were reported in 6.5% (13/201) and access site-related complications in 3.0% (6/201) of cases. Five-year KM estimates were: 72.1% for primary patency, 89.6% for secondary patency, and 79.6% for overall survival. No significant difference in primary patency was observed between techniques (p = 0.55), and one case of major limb amputation was reported after 5 years. Conclusions: EVT using the kissing stent or CERAB technique is a durable and safe treatment for complex AIOD in high-risk patients over 5 years, with favorable outcomes and low periinterventional morbidity and mortality.

Background: In patients with chronic limb-threatening ischemia (CLTI), accurate assessment of the patient's prognosis is crucial to guide decision-making and therapy. The Global Vascular Guidelines on CLTI suggest the multifactorial acronym PLAN, consisting of estimations of Patient risk, Limb severity and Anatomical complexity of disease. After a recent meta-analysis, we constructed and validated a risk score consisting of the GermanVasc CLTI, Wound Ischemia and foot Infection (WIfI), and Global Limb Anatomic Staging System (GLASS) scores. Methods: A retrospective analysis of patients suspected of having CLTI who were evaluated in our multidisciplinary team between 2018 and 2019 was performed. A random limb per patient was chosen for analysis. A Cox proportional hazards model was created using previously published hazard ratios for the GermanVasc score, and remodeled to include & horbar;and fit a model on & horbar;the WIfI and GLASS score. Bootstrap analysis and corrected c-statistics were performed. Secondary analysis was performed on limbs not included in the model creation, providing Kaplan-Meier amputation-free survival curves and comparing receiver operating characteristics plots between the PLAN model and the individual component scores. A scatterplot of PLAN risk points vs 1-year amputation or death probability was created. Results: A total of 394 patients were included, with a median follow-up of 22.7 months. Complementing the GermanVasc score with 0, 6, 7, or 8 points for WIfI stages 1 to 4, respectively, and 3, 6, 7, or 12 points for GLASS stages 0 to 3 respectively, with 0 points if no imaging was available, showed a good discrimination (optimism corrected-c= 0.71 [0.67-0.77]). Overall 1-year amputation-free survival was 83.2% (79.3%-87.1%), ranging from 94.0% (89.5%-98.8%) in the low-risk group (0-8 points), to 55.9% (45.8%-68.1%) in the high-risk group (22-61 points). PLAN risk points had a significantly higher area under the receiver operating characteristic curve than WIfI (P < .01), GLASS (P < .01), and GermanVasc (P < .05). Conclusions: A single score integrating the components of the Global Vascular Guidelines' PLAN concept for revascularization, combining GermanVasc CLTI score, WIfI, and GLASS, resulted in a significant improvement of risk assessment in patients with CLTI. (JVS-Vascular Insights 2026;4:100431.)

Abstract Objective To evaluate the long-term safety and efficacy of the pave-and-crack technique, combining aggressive balloon dilatation and covered stent implantation, for endovascular therapy (EVT) of highly calcified femoropopliteal chronic total occlusions (CTOs) in poor surgical candidates unsuitable for open revascularization or conventional EVT. Design Single-center retrospective cohort study based on a prospectively maintained peripheral artery disease database. Methods Patients with symptomatic femoropopliteal CTOs treated using the pave-and-crack technique between September 2014 and April 2025 were included. Lesion and procedural characteristics, technical success, defined as residual stenosis ≤ 30%, complications, major target limb amputation, and symptom status were assessed. Kaplan–Meier analysis was used to estimate freedom from target lesion revascularization (TLR) and all-cause mortality through 5 years. Results A total of 122 patients with 136 femoropopliteal CTOs were treated. Mean lesion length was 253.0 ± 90.1 mm, and 93.4% (127/136) of lesions were severely calcified. Retrograde access was required in 72.8% (99/136) of procedures. Technical success was achieved in 93.4% (127/136). Freedom from target lesion revascularization was 91.4% ± 2.6% at 1 year, 77.9% ± 4.6% at 3 years, and 66.7% ± 7.2% at 5 years. Major target limb amputation occurred in four cases presenting with CLTI (8.5%; 4/47) and none with claudication (0%; 0/89). Five-year freedom from all-cause mortality was 71.4 ± 6.9% for claudicants and 41.4 ± 11.2% for patients with CLTI ( p < 0.01). Conclusion The pave-and-crack technique is feasible for highly calcified femoropopliteal CTOs, achieving high technical success, encouraging long-term freedom from TLR, and high limb salvage. Graphical Abstract Long-Term Outcomes of the “Pave-and-Crack” Technique for Severely Calcified Femoropopliteal Chronic Total Occlusions. (Left) Lesion and Procedural Characteristics. (Middle) the “Pave-and-Crack” Technique (A) Fluoroscopy showing aggressive balloon pre-dilatation. (B) Angiography showing vessel rupture. (C) Fluoroscopy following covered stent implantation (Viabahn) and relining with an interwoven nitinol stent (Supera). (D) Final angiography. (Right) Kaplan Meier survival curves and estimates for freedom from target lesion revascularization over five years stratified for popliteal involvement (segment P1-P3). CLTI: Chronic limb threatening ischemia. CTO: Chronic total occlusion. PACSS: Peripheral Calcification Scoring System. PTA: Percutaneous transluminal angioplasty. KM: Kaplan-Meier, SD: Standard deviation, TLR: Target lesion revascularization.

After vessel preparation, using different strategies such as balloon angioplasty, specialty balloons, atherectomy or intravascular lithotripsy, definitive treatment has emerged as a key feature in endovascular treatment strategies. Based on current guidelines, endovascular treatment is the most common treatment option in patients with claudication. In patients with chronic limb-threatening ischemia (CLTI), on the other hand, the best treatment modality, including bypass surgery and endovascular revascularization, needs to be selected by an interdisciplinary team, focusing on individual anatomic and patient-specific characteristics, on the availability of a vein graft and on cardiovascular and other comorbidities of the patients. With endovascular therapy, currently, a plethora of options are available for the treatment of femoropopliteal lesions, which are increasingly gaining in complexity. Therefore, a practical systematic case-based approach, entailing contemporary treatment options, like drug-coated balloon (DCB) angioplasty tools, self-expanding bare-metal stents (BMSs), drug-eluting stents (DESs), interwoven stents and covered stents, is crucial. Generally, most endovascular operators adhere to the ‘leave nothing behind’ concept, meaning that, after proper lesion preparation, lesions can be treated with DCBs, avoiding the implantation of permanent metallic implants. However, in the case of severe dissections or significant recoil, stent implantation becomes necessary to achieve adequate limb perfusion. The selection between long versus spot stenting and the different stent options depends on the current scientific evidence, guidelines and expert opinion statements. An interdisciplinary expert consensus was recently compiled on how these modalities should be used in specific lesions and patients in the femoropopliteal segment. Herein we present a practical case-based approach, which is based on this algorithm and aims at harmonization of endovascular treatment strategies in daily practice and ultimately at further improvements in limb and patient outcomes.

The randomised SIRONA trial showed that sirolimus-coated balloon (SCB) angioplasty was non-inferior to paclitaxel-coated balloon angioplasty (PCB) regarding femoropopliteal primary patency. There was no difference in clinically driven target lesion revascularisation (cdTLR) rates between the treatment groups. This post-hoc analysis aimed to assess whether the overall results were consistent across different subgroups and selected post-baseline factors. Primary patency at 12 months was assessed using duplex ultrasound and adjudicated by a core laboratory for 203 and 199 participants in the SCB and PCB groups, respectively (available-case intention-to-treat analysis). Data on 12-month cdTLR were available for 238 and 244 participants in the SCB and PCB groups, respectively. Odds ratios (ORs) for primary patency and hazard ratios (HRs) for cdTLR after SCB compared to PCB in non-pre-specified subgroups were assessed using generalised linear mixed models to control for centre effects, and Cox proportional hazards models, respectively. Primary patency and cdTLR were generally consistent across the analysed subgroups. Two nominal interaction signals were observed. For cdTLR, a nominal interaction with age was identified (interaction p = 0.047); among participants older than 70 years, the estimated hazard ratio favoured SCB (HR 0.52, 95 https://clinicaltrials.gov/study/NCT4475783 .

BACKGROUND:Paclitaxel-coated balloon (PCB) angioplasty is effective for femoropopliteal interventions. However, the increased mortality risk associated with PCB has not yet been cleared, and alternative antiproliferative drugs may offer additional advantages. OBJECTIVES:The authors aimed to investigate whether sirolimus-coated balloon (SCB) angioplasty achieves noninferior primary vessel patency and clinical efficacy and safety compared with PCB angioplasty. METHODS:SIRONA is a multicenter randomized, controlled, noninferiority trial comparing SCB with PCB angioplasty in patients with symptomatic femoropopliteal artery disease. The study was conducted at 25 centers in Germany and Austria. Patients aged 18 years or older with a single target lesion were randomized 1:1 using permuted blocks, stratified by center. Participants and outcome assessors were masked to allocation. Primary endpoints were primary patency and the composite clinical endpoint of freedom from clinically driven target vessel revascularization, major target limb amputation, and device- or procedure-related death at 12 months based on available case intention-to-treat analysis. Prespecified noninferiority margins were 10%. Long-term follow-up is ongoing. RESULTS:Between April 21, 2021, and September 23, 2022, 482 patients were assigned to SCB (n = 238) or PCB (n = 244) groups. The mean age was 68.0 ± 8.9 years; 311 participants (64.5%) were male; and 464 participants (96.3%) presented with intermittent claudication. Mean lesion length was 8.4 ± 6.1 cm and 160 lesions (33.2%) were chronic total occlusions. Primary patency was achieved in 150 of 203 participants (73.9%) with SCBs and in 149 of 199 participants (74.9%) with PCBs (risk difference: -1.0%; 95% CI: -9.6% to 7.6%; Pnoninferiority = 0.019). However, sensitivity analyses revealed that noninferiority was achieved but statistically not robust. The primary clinical endpoint was achieved in 199 of 220 participants (90.5%) with SCBs and in 202 of 218 participants (92.7%) with PCBs (risk difference: -2.2% (95% CI: -7.7% to 3.2%.); Pnoninferiority = 0.003). These results were confirmed by sensitivity analyses. CONCLUSIONS:Among patients with femoropopliteal artery disease, SCBs demonstrated noninferior clinical important outcomes and comparable improvement in vascular quality of life compared with PCBs. Although the noninferiority of primary patency was not statistically robust, this suggests that SCBs may be a valuable alternative to PCBs. (Sirolimus- vs Paclitaxel-Drug Coated Balloons in Patients With Peripheral Artery Disease [SIRONA]; NCT04475783]; Head-to-Head Comparison of Sirolimus vs Paclitaxel Drug-Eluting Balloon Angioplasty in the Femoropopliteal Artery [SIRONA]; DRKS00022452).

BACKGROUND:Drug-coated balloons improve outcomes after femoropopliteal angioplasty, but concerns regarding the long-term safety of paclitaxel-coated devices have prompted interest in alternative antiproliferative strategies. OBJECTIVES:This study sought to evaluate the 2-year patient-centered and clinical outcomes of sirolimus-coated balloon (SCB) versus paclitaxel-coated balloon (PCB) angioplasty. METHODS:SIRONA was a prospective, multicenter, randomized, controlled, noninferiority trial comparing SCB with PCB angioplasty in patients with femoropopliteal artery disease (96.5% intermittent claudication). The present analysis reports prespecified outcomes at 2 years. Effectiveness endpoints included patient-reported outcomes (VascuQol, clinical improvement, and EQ-5D-3L), primary patency, and freedom from clinically driven target lesion revascularization. Safety endpoints included major amputation and all-cause mortality. Longer-term follow-up is ongoing to assess durability and safety up to 5 years. RESULTS:A total of 482 patients was randomized (SCB: n = 238; PCB: n = 244). Improvements in vascular quality of life were sustained through 2 years and were similar between groups (between-group difference: 0.05, 95% CI: -0.15 to 0.24; P = 0.63). Clinical improvement (≥1 Rutherford category) occurred in 88% of the SCB group and 89% of the PCB group (P = 0.89). Kaplan-Meier estimates of primary patency were 64.6% for SCB and 67.2% for PCB (log-rank P = 0.34). Freedom from clinically driven target lesion revascularization was 91.2% for SCB and 88.1% for PCB (log-rank P = 0.42). Major amputation was rare (0.4% in both groups). All-cause mortality occurred in 6.3% and 3.7%, respectively (P = 0.21), with no device- or procedure-related deaths. CONCLUSIONS:SCB angioplasty resulted in sustained patient-reported and clinical outcomes comparable to PCB angioplasty through 2 years, with similar patency, revascularization, and safety.

Background: In patients suspected for peripheral arterial disease and who are at risk for arterial calcification, measurement of the toe pressure (TP) is preferred over the ankle-brachial index, owing to an alleged reduced susceptibility for calcification in the digital arteries. Recent studies, however, have shown that calcification of digital arteries is prevalent in chronic limb-threatening ischemia patients. This study examined the influence of digital artery calcification in suspected chronic limb-threatening ischemia on the measured TP. Methods: We conducted a single-center, retrospective analysis of patients reporting to a multidisciplinary vascular clinic. All patients had bilateral TP measurements, and patients without radiographs of the foot were excluded. Cox proportional hazard modelling was performed for 1-year major adverse limb events (MALEs) between patients with and without digital artery calcification. Propensity score matching was performed to create comparable groups of patients with and without digital artery calcification and included known confounders for the presence of digital artery calcification. TP was plotted against a calculated probability of 1 year MALE-free survival for both matched Results: Four hundred ninety-four limbs in 382 patients were included, of which 143 had radiographical signs of digital artery calcifications (28.9%), and 351 (71.1%) had not. Digital artery calcification had a 2.51 hazard ratio (95 confidence interval, 1.68-3.73) for MALE-free survival. One hundred sixty-five patients were matched. The probability of 1-year MALE-free survival increased with decreasing systolic TP in both calcified and noncalcified digital arteries. Overall, a 20 to 30 mm Hg difference between groups is visualized for each estimate of risk. Conclusions: Calcification of the arteries of the first toe is present in 27.2% of patients, which significantly reduces MALEfree survival, with a hazard ratio of 2.5. For an adequate assessment of ischemia risk, when medial arterial calcification is present in radiographic imaging of the foot, we advise to subtract 20 to 30 mm Hg of the TP measurement. (JVS Vascular Insights 2026;4:100429.)

We describe the use of a 0.009-inch tapered-tip guidewire to achieve successful revascularization of tibial chronic total occlusions in a patient with chronic limb-threatening ischemia initially referred for major amputation. Initial revascularization attempts using multiple non-tapered 0.014-inch and 0.018-inch guidewires were unsuccessful. Subsequent use of 0.009-inch and 0.010-inch tapered-tip guidewires enabled intraluminal crossing of the tibioperoneal trunk, posterior tibial, and peroneal artery CTOs, followed by angioplasty and restoration of in-line flow. This case highlights the feasibility of leveraging microchannels within peripheral CTOs using tapered-tip guidewires to achieve successful revascularization and limb salvage.

BACKGROUND:Percutaneous sacroiliac screw fixation is an effective option for unstable pelvic ring fractures. It is minimally invasive, causes little soft tissue damage, and reduces complication risk. Nevertheless, complications such as screw loosening or nerve root damage are reported. Although vascular injuries are also described, detailed management strategies are rarely found in the literature. CASE PRESENTATION:A 58-year-old white German female suffered polytrauma, including a type c posterior pelvic ring fracture, after a fall from great height. The fracture was treated with screw osteosynthesis of the anterior and posterior ring. After transfer to our hospital for further treatment, X-ray and CT revealed sacroiliac screw malposition with suspected external iliac vein injury. During an interdisciplinary procedure involving angiology and trauma surgery, the screw was removed, and subsequent bleeding from the injured vein was controlled by coiling before a new sacroiliac screw was inserted. The subsequent hospital stay remained complication free. CONCLUSIONS:Sacroiliac screw osteosynthesis is a safe and established procedure for unstable pelvic ring injuries. However, due to complex anatomy such as sacral dysmorphia and difficult fracture patterns, complications including nerve or vascular injury may occur. Preventing these requires careful preoperative planning to identify a suitable corridor. While 2D-fluoroscopy is well established intraoperatively, 3D-navigation further reduces malposition risk in challenging anatomy. In cases of screw malposition, exact analysis and interdisciplinary consultation are essential to determine the safest and most effective treatment and to successfully manage complications. KEY CLINICAL MESSAGE:The incorrect positioning of a sacroiliac screw can lead to serious complications. Exact analysis and the full spectrum of complication management is necessary for successful treatment of misplaced screws in pelvic surgery.

CASE SUMMARY:A 62-year-old man presented with a long-standing history of a nonhealing ulcer to the left foot. Previous antegrade revascularization attempts failed. Retrograde access was obtained at the posterior tibial artery, but the wire traveled away from the tibial peroneal trunk and connected at the popliteal artery. Intravascular ultrasound confirmed intraluminal passage of the wire, which led to successful revascularization of the posterior tibial artery and ulcer healing. TAKE-HOME-MESSAGE:The RIVER (Retrograde Intravascular ultrasound Endovascular Revascularization of Anomalous Tibial Chronic Total Occlusions) technique is a useful strategy for revascularization of anomalous tibial occlusions when standard antegrade approaches fail.

Contrast-associated acute kidney injury (CA-AKI) is a known complication of endovascular procedures using an iodinated contrast medium (ICM), especially in patients with peripheral artery disease (PAD) and chronic kidney disease (CKD). This retrospective study evaluated the incidence and risk factors of AKI in patients with PAD and CKD undergoing diagnostic angiography or endovascular intervention using carbon dioxide (CO2) as the primary contrast medium, with optional bailout ICM use. We included 340 patients who underwent peripheral angiography or intervention between September 2014 and December 2020. CO2 was used as the primary contrast medium for all patients, as the majority were classified with advanced CKD stages 3–5 according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Bailout ICM was used in 80% of cases (mean 21.23 ± 14.09 mL). Postinterventional AKI occurred in 13.2% of patients, with over 70% classified as stage 1. Seven patients required new dialysis within 7 days. Multivariate analysis identified hypertension, heart failure, and coronary artery disease as independent AKI risk factors. Statin or Renin–Angiotensin–Aldosteron System (RAAS) inhibitor use and higher pre-interventional GFR were protective. AKI remains common in patients undergoing CO2-guided peripheral procedures. Further studies are needed to explore underlying mechanisms and outcomes.

Background/Objectives: Our aim was to assess the feasibility of hyperspectral imaging (HSI) to detect changes in tissue oxygenation (StO2) of the back, as non-invasive spinal cord collateral network (CN) monitoring during staged endovascular repair (ER) of thoracoabdominal aortic aneurysm (TAAA). Methods: Between September 2019 and June 2021, 20 patients were treated for TAAA and underwent HSI. They were randomized 1:1 to minimally invasive staged segmental artery coil embolization (MIS2ACE) (n = 10) and staged stentgraft implantation (n = 10) as priming methods. HSI of paravertebral regions was taken during each procedure and up to 10 days after. The primary endpoint was the identification of StO2 changes after ER of TAAA. Results: TAAA Crawford Type II (n = 17) and Type III (n = 3) were treated. After stentgrafting, StO2 increased immediately (p < 0.001), followed by a decrease after 5 days (p < 0.001) and 10 days (p = 0.028). StO2 was significantly higher in the thoracic compared to the lumbar region. There was no significant difference between MIS2ACE and the first stentgrafting for StO2 (p = 0.491). Following MIS2ACE, definitive ER caused a significant decrease in StO2 after 5 days (p = 0.021), which recovered to baseline after 10 days (p = 0.130). After stentgraft priming, definitive ER caused a significant decrease in StO2 after 24 h (p = 0.008), which did not return to baseline after 5 (p < 0.001) and 10 days (p = 0.019). Conclusions: HSI detected significant changes in StO2 in the thoracic and lumbar paravertebral regions during ER of TAAA. These preliminary data suggest the efficacy of MIS2ACE in priming the CN before ER of TAAA.

A global treatment algorithm was developed for the endovascular revascularization of femoropopliteal lesions and chronic total occlusions, aiming toward a more standardized approach to endovascular treatment in patients with peripheral artery disease. The following steps are proposed. 1) Evaluation of lesion morphology based on preprocedural imaging by Duplex sonography and intravenous ultrasound for selection of lesion preparation tools. Lesion characteristics are mainly defined by calcification, lesion length, and the presence of total occlusion and in-stent restenosis. 2) Selection of vessel preparation strategies, which encompass plain old balloon angioplasty, atherectomy, thrombectomy, intravascular lithotripsy and specialty balloons, or a combination of the preceding, based on lesion and patient-specific characteristics. In addition, a Delphi consensus was applied for the appropriateness of lesion preparation strategies, depending on lesion anatomy, length, plaque morphology, and subintimal versus intraluminal guidewire crossing. 3) Definitive lesion treatment strategies using drug-coated balloons, bare-metal stents, drug-eluting stents, and/or covered stents or a combination. By establishing this treatment algorithm in routine practice, improvements in vessel- and patient-specific outcomes are anticipated, which will be further enhanced by continuous collaboration among experts from different countries and disciplines and by randomized controlled trials.

Vessel preparation has emerged as a key feature in endovascular treatment strategies as treated lesions are increasingly complex. While treatment algorithms have been presented, a practical systematic case-based approach, entailing contemporary vessel preparation tools, would provide assistance for vascular specialists in the daily routine. Based on patient characteristics, including clinical presentation, age and comorbidities and lesion specific parameters, team-based and patient-centered decisions are necessary for successful treatment. In addition, pre- and procedural imaging, lesion specific characteristics, such as the presence of chronic total occlusions, lesion length and calcification or the presence of thrombus are evaluated. Furthermore, run-off vessels serving as potential conduits for retrograde puncture in case of failed antegrade crossing need to be considered. Based on lesion-specific variables and the type of crossing (intraluminal versus subintimal), options for lesion preparation techniques, including plain-old-balloon angioplasty (POBA), specialty balloons, atherectomy, intravascular lithotripsy and/or thrombectomy are selected prior to the definitive treatment of the lesion. The selection of such vessel preparation strategies depends on the current scientific evidence, guidelines and expert opinion statements. Treatment of patients with intermittent claudication or chronic limb threatening ischemia (CLTI) are now discussed, where a recently published lesion preparation algorithm is applied. By the establishment of this algorithm in daily practice, harmonization of endovascular practice and further improvements in vessel and patient specific outcomes are anticipated.

Background: To evaluate the safety and efficacy of direct retrograde stent punctures for crossing of chronic total occlusions in patients with symptomatic peripheral arterial disease. Methods: A retrospective registry of consecutive patients treated with retrograde recanalization techniques in five high-volume German centers was performed. Patient cases with attempted retrograde after failed antegrade revascularization were studied. Primary endpoint was technical success. Secondary endpoints were access vessel complications, need for bail-out procedures and major or minor amputation. Results: Of the 1516 retrograde punctures recorded in the registry, 63 (4.2%) were direct stent punctures. Superficial femoral artery stents were punctured in 88.9% (56/63) of the cases, tibial artery stents in 6 patients (9.5%) and a stent in an occluded femoropopliteal bypass in one case (1.6%). Mean lesion length was 322±125 mm. Stent puncture was successful in 62 cases (98.4%) and the procedural success rate was 96.8% (61/63) with one technical failure despite successful puncture. A sheathless approach was performed in 79.4% (50/63) of cases. Drug-coated balloon angioplasty was applied in 63.5% (40/63) and new stenting (bare-metal or drug-eluting) in 55.6% (35/63) of lesions. One minor and no major amputations were recorded in the first 30 days after the procedure. A sheathless retrograde approach was associated with significantly higher procedural technical success (p = .04). Conclusion: Retrograde femoral or tibial direct stent puncture seems to be safe and effective for the recanalization of chronic total occlusions of the femoropopliteal segment in cases where antegrade recanalization is deemed unsuccessful.