PURPOSE:To describe a novel technique for achieving reliable hemostasis after retrograde popliteal or proximal below-the-knee (BTK) arterial access, particularly in larger-profile interventions, through trans-sheath injection of a hemostatic matrix with thrombin to seal the percutaneous tract. TECHNIQUE:Following completion of the endovascular procedure, a guidewire is advanced from the antegrade femoral access across the retrograde puncture site, and an appropriately sized balloon catheter is positioned at this level. The retrograde sheath is gently withdrawn under aspiration until extraluminal placement is confirmed. The balloon is then inflated, and the hemostatic matrix with thrombin is injected through the sheath lumen to occlude the tract. After 3 minutes, angiography is performed to ensure complete hemostasis, vessel integrity, and preserved distal flow. RESULTS:The method was applied in 21 consecutive cases (15 popliteal, 6 BTK) requiring access site ≥ 5F. Primary technical success was 95.2% (20/21). In 1 patient, an additional 5 minutes of balloon compression was required. No secondary complications, including pseudoaneurysm, thrombosis, infection, or distal embolization, were observed during 30-day follow-up. CONCLUSION:This closure strategy using trans-sheath delivery of hemostatic matrix with thrombin is feasible, safe, and reproducible, offering effective hemostasis after increased-bore retrograde popliteal or proximal BTK accesses.Clinical ImpactThis technique provides a reliable and reproducible solution for achieving hemostasis following retrograde popliteal and proximal below-the-knee arterial access, particularly in procedures requiring larger sheath sizes. By combining balloon occlusion with trans-sheath delivery of a hemostatic matrix containing thrombin, it minimizes the risk of access-site complications such as bleeding, pseudoaneurysm formation, and distal embolization. This approach may expand the safe use of retrograde access in complex peripheral interventions, reduce the need for prolonged manual compression or surgical repair, and improve overall procedural efficiency and patient outcomes.

BACKGROUND:Peripheral artery disease (PAD) is a global health challenge. Advances in artificial intelligence (AI), such as large language models (LLMs) and chain-of-thought (CoT) reasoning, offer novel approaches for clinical recommendations. This study compared the readability and guideline adherence of responses from physicians and AI for a standardized PAD case. METHODS:This cross-sectional study gathered responses from 30 specialized physicians (11 cardiologists, 19 vascular surgeons) across seven Latin American countries and 13 LLM systems (10 standard, three CoT). Both groups addressed diagnosis, treatment, risks, and prognosis; LLMs responded as vascular specialists. Responses were blindly evaluated with five validated Spanish readability indices and compared to the 2024 ACC/AHA multisocietal PAD guideline. Three experts scored guideline adherence; nonparametric tests were applied. RESULTS:Guideline adherence did not differ significantly between physicians (median 5.8 [3.4-7.6]) and LLMs (7.3 [4.7-9.7], p = 0.169), though CoT-LLMs achieved the highest scores (9.7 [8.5-11.0]). LLMs more often recommended supervised exercise (84.6% vs 30.0%, p = 0.002) and revascularization for quality of life (69.2% vs 20.0%, p = 0.004), whereas physicians favored cilostazol (60.0% vs 30.8%, p = 0.104). LLM responses had lower Readability μ values (46.9 vs 51.4, p = 0.012). Inter-rater reliability was highest for CoT-LLMs (intraclass correlation coefficient [ICC] = 0.98) versus physicians (ICC = 0.76). CONCLUSION:LLM showed comparable guideline adherence to physicians although CoT models achieved the highest scores. The difference in physician and AI treatment preferences suggest the potential of AI as adjunct clinical tools and warrants further study.

Summary: When a peripheral arterial stenosis/occlusion can be crossed by a guidewire, but no device can follow over it, to have proficiency in bailout strategies which allow device crossing can be beneficial. Limited information is available on these bailout manoeuvres. This article aims to provide a comprehensive pictorial review of various bailout techniques, equipping operators with an algorithm to apply in specific scenarios, to eventually improve procedural success rates.

Purpose: To describe a novel bailout technique to approach below-the-ankle (BTA) chronic total occlusions or plantar-arch severe disease where the balloon/catheter is unable to follow the crossing guidewire and no other described recanalization approach is feasible. Technique: When facing a complex BTA revascularization, if the guidewire crosses but the balloon cannot progress due to a lack of pushability, an antegrade puncture of the infrapopliteal vessel where the tip of the guidewire lays is performed. The guidewire is then carefully navigated through this distal BTA vessel into the needle to achieve its rendezvous and externalization. A low-profile balloon is inserted through the femoral access and advanced till the non-crossable point of the BTA vessels. A torque device is then attached to the proximal hub of the balloon, and the through-and-through guidewire is subsequently pulled from the new distal access, allowing the balloon to be dragged across the lesion together with the wire. Conclusion: The below-the-ankle antegrade teleferic (BAT) technique may be considered for highly complex BTA revascularization procedures where the wire crosses the lesion, but no other device can be tracked over it. Clinical Impact The clinical impact of this article lies in the description of a bailout technique for BTA revascularization where the guidewire crosses, but no device can be advanced. This technique can be helpful in scenarios where failure to achieve success could result in limb loss. The BAT technique provides a solution in extremely challenging cases, enhancing technical success, improving outcomes and potentially preserving the limbs of patients who would otherwise face amputation, if not revascularized. The video shows the BAT technique performed with a support catheter under fluoroscopy: antegrate puncture of the DP, advancement of the support catheter over the wire, rendezvous of the guidewire in the catheter and subsequent externalization of the wire.

PURPOSE:The purpose of the study is to describe a bailout technical strategy to prevent below-the-knee (BTK) distal embolization during procedures with increased inherent risk using universally-available "off-the-shelf" devices. TECHNIQUE:A conventional retrograde access is obtained of the BTK target vessel where embolization protection is sought. Before starting any potential proximal maneuver with an associated significant risk of distal embolization (eg, atherectomy and mechanical thrombectomy), a low-profile balloon is inserted and inflated through the distal retrograde access, so that any debris resulting from the recanalization procedure is blocked by the stagnant column of blood generated by the inflated balloon. Once the revascularization procedure has been completed, a 4F curved catheter is antegradely advanced down to the distally-inflated balloon, and in case of distal embolization the debris is aspirated in a standard fashion way. CONCLUSION:A retrograde balloon-assisted "off-the-shelf" embolic protection approach may be considered for BTK revascularization procedures where there is an inherent increased risk of distal trash, especially in the presence of distal single-vessel runoff. CLINICAL IMPACT:Distal embolization following endovascular procedures can have devastating consequences and there is a general recommendation for selective use of EPDs in high-risk-scenarios. The increased cost and low availability of the current EPD devices for BTK/BTA arteries have prohibited their widespread use. The retrograde balloon-assisted "off-the-shelf" EPD prevents distal embolization during procedures with increased risk of distal trash using inexpensive, nonspecific equipment available in any basic endovascular suite.

Lower limb complex arterial obstructions can be difficult to treat by standard endovascular means. Different technical strategies, such as the retrograde puncture of below-the-knee (BTK) vessels, the plantar loop technique, or the transcollateral approach, have been described to approach BTK or below-the-ankle (BTA) chronic total occlusions after a failed antegrade recanalization attempt. However, when the disease progresses into the foot or the plantar arch cannot be crossed for a bidirectional approach, the necessity for mastering extreme distal punctures increases. This review is to summarize different tips and tricks to help operators apply them when facing these complex punctures.Clinical Impact When the standard endovascular crossing maneuvers have failed during CLTI recanalization procedures and the distal below-the-knee or proximal below-the-ankle retrograde access is not possible due to chronic occlusion of the vessels, mastering the more distal and complex retrograde BTA punctures may be advantageous.There are scanty reports regarding the retrograde puncture of the mid and forefoot vessels. The aim of this article is to review different tips and tricks related to these techniques to help operators to apply them in specific scenarios to eventually improve procedural success rate.

OBJECTIVE:To evaluate the clinical efficacy of a new antioxidant therapy for the treatment of complex neuroischaemic diabetic foot ulcers (DFUs).METHOD:A prospective case series study has been conducted in patients with complex neuroischaemic DFUs after transmetatarsal amputation. DFUs were locally treated with an antioxidant dressing twice a week for the first two weeks, and then once a week until the end of the study or complete wound closure. Patients were followed-up for eight weeks and assessed weekly to analyse wound outcome. Primary outcomes were the wound closure ratio and percentage of granulation tissue; secondary outcomes were parameters related to wound management, namely, presence of non-viable tissue in the wound bed, levels of maceration and exudates, presence of erythema and pain.RESULTS:A total of 20 patients were included with a mean baseline wound area of 20.4cm2. At 8 weeks, the mean reduction in wound area was 88.1% (p<0.0001) and complete closure was observed in 33% of cases. In addition, there was a mean increase of 94.7% in granulation tissue in the wound bed (p<0.0001). Furthermore, the therapy was associated with a significant percentage reduction in wounds with non-viable tissue, good exudate management, and the maintenance of low levels of maceration, erythema and pain.CONCLUSION:The new antioxidant therapy was associated with good clinical outcomes in large hard-to-heal neuroischaemic DFUs, with significant wound area reduction and granulation tissue formation. The therapy was also found to be safe and perform well from a practical perspective.

One of the main skillsets required to tackle endovascular revascularization of complex peripheral chronic total occlusions (CTOs) is wire crossing into the distal true lumen. There are a lot of factors that influence the use of specific catheter and wire strategies, and these include vessel calcification, occlusion length, previous stents, vessel reconstitution zone, availability of retrograde access, operator experience, and available equipment of the shelf. More than the last 2 decades, various dedicated CTO devices have been developed to meet these specific clinical needs; however, their widespread use has been limited by the lack of availability around the world and considerable cost. Hence, the ability to cross complex lesions with the use of widely available simple catheters and wires is crucial for effective limb salvage in this significantly undertreated patient population. The customization of specific techniques to treat individual patients and anatomical subsets is one of the most creative and innovative aspects of the endovascular revascularization field.Clinical ImpactInfra-inguinal Chronic Total Occlusions recanalisation is considered technically challenging. The conventional manipulation of standard guidewires and catheters has proven to be successful in a considerable percentage of cases but success rate could dramatically drop in presence of challenging lesions. The additional use of retrograde access and re-entry devices could increase technical success but could negatively affect procedural time and overall costs. Twenty different techniques of Chronic Total Occlusions antegrade crossing are hereby described with appropriate schematic representations. The aim is to help operators to apply them in specific anatomy subsets and clinical presentations and ultimately to increase procedural success rate.

PURPOSE:To describe a novel bailout technique to approach below-the-knee chronic total occlusions after a failed bidirectional recanalization attempt using the plantar loop maneuver in patients who are poor candidates for a retrograde puncture.TECHNIQUE:After a failure of recanalization of the opposite tibial artery using the plantar loop maneuver, an assisted direct retrograde transpedal approach can be performed regardless of poor vessel caliber or even arterial occlusion. After crossing the plantar arch, a low profile angioplasty balloon is used as a landmark for the pedal puncture and to give guidance for the wire advancement from the new access.CONCLUSION:A balloon-assisted retrograde transpedal approach may be considered for below-the-knee recanalization after standard plantar loop technique failure in patients who are not candidates for conventional retrograde puncture.

We read with great interest the article entitled “Open, percutaneous, and hybrid deep venous arterialization technique for no-option foot salvage” by Ho et al.1Ho V.T. Gologorsky R. Kibrik P. Chandra V. Prent A. Lee J. et al.Open, percutaneous, and hybrid deep venous arterialization technique for no-option foot salvage.J Vasc Surg. 2020; 71: 2152-2160Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar We would like to congratulate the authors for their interesting review of this lower limb “hot topic.” However, with regard to percutaneous venous arterialization, the article has skipped some approaches (other than the LimFlow system [LimFlow SA, Paris, France]) already published in different accredited journals with similar number of cases and outcomes equivalent to those included in this study (Table).TableSummary of literature describing outcomes in percutaneous deep venous arterializationStudyNo.IndicationTarget veinFollow-up, monthsPrimary patency, %Limb salvage, %Wound healing, %Major amputation %Rest pain resolved, %ComplicationsMortality, %Postoperative medicationDel Guidice7Del Giudice C. Van Den Heuvel D. Wille J. Mirault T. Messas E. Ferraresi R. et al.Percutaneous deep venous arterialization for severe critical limb ischemia in patients with no option of revascularization: early experience from two European centers.Cardiovasc Intervent Radiol. 2018; 41: 1474-1480Crossref PubMed Scopus (25) Google Scholar5Rutherford classes 4-6PTV (4)ATV (1)6406040201006020Kum8Kum S. Huizing E. Schreve M.A. Unlu C. Ferraresi R. Samarakoon L.B. et al.Percutaneous deep venous arterialization in patients with critical limb ischemia.J Cardiovasc Surg (Torino). 2018; 59: 665-669Crossref PubMed Scopus (20) Google Scholar7CLI without candidacy for angioplasty or open bypassPTV1028.67171.428.514.2−0Clopidogrel and warfarin for 3 months, then lifelong aspirin or clopidogrelMustapha6Mustapha J.A. Saab F.A. Clair D. Schneider P. Interim results of the PROMISE I trial to investigate the LimFlow system of percutaneous deep vein arterialization for the treatment of critical limb ischemia.J Invasive Cardiol. 2019; 31: 57-63PubMed Google Scholar10Rutherford classes 5 and 6PTV (6)690 at 1 month40 at 6 months861000−−0−Migliara5Migliara B. Cappellari T.F. A novel technique to create an arteriovenous fistula during total percutaneous deep foot venous arterialisation using an IVUS guided catheter.Eur J Vasc Endovasc Surg. 2018; 55: 735Abstract Full Text Full Text PDF Scopus (11) Google Scholar16Rutherford classes 5 and 6PTV4.437.566.726.731.25100−25Warfarin and aspirinGandini2Gandini R. Merolla S. Scaggiante J. Meloni M. Giurato L. Uccioli L. et al.Endovascular distal plantar vein arterialization in dialysis patients with no-option critical limb ischemia and posterior tibial artery occlusion: a technique for limb salvage in a challenging patient subset.J Endovasc Ther. 2018; 25: 127-132Crossref Scopus (26) Google Scholar9CLI without candidacy for angioplasty or open bypass WIfI score 3-4MPV(2)LPV (5)685676733.3−No major complications0Dual antiplatelet therapyYsa3Ysa A. Lobato M. Mikelarena E. Arruabarrena A. Gómez R. Apodaka A. et al.Homemade device to facilitate percutaneous venous arterialization in patients with no-option critical limb ischemia.J Endovasc Ther. 2019; 26: 213-218Crossref Scopus (21) Google Scholar5CLI without candidacy for angioplasty or open bypass WIfI score 3-4Distal PTV (4)MMV (1)675757520100No major complications0Aspirin and oral anticoagulationATV, Anterior tibial vein; CLI, critical limb ischemia; LPV, lateral plantar vein; MMV, medial marginal vein; MPV, medial plantar vein; PTV, posterior tibial vein; WIfI, Wound, Ischemia, and foot Infection. Open table in a new tab ATV, Anterior tibial vein; CLI, critical limb ischemia; LPV, lateral plantar vein; MMV, medial marginal vein; MPV, medial plantar vein; PTV, posterior tibial vein; WIfI, Wound, Ischemia, and foot Infection. In our opinion, it is important that these other approaches be discussed in a state-of-the-art review because the LimFlow device is still not available in most countries, and the majority of physicians are currently performing percutaneous deep venous arterialization using these alternative methods. Gandini et al2Gandini R. Merolla S. Scaggiante J. Meloni M. Giurato L. Uccioli L. et al.Endovascular distal plantar vein arterialization in dialysis patients with no-option critical limb ischemia and posterior tibial artery occlusion: a technique for limb salvage in a challenging patient subset.J Endovasc Ther. 2018; 25: 127-132Crossref Scopus (26) Google Scholar described a maneuver (based on the anatomic disposition of the double vein neighboring the plantar arteries) of creating a distal plantar vein arterialization by pointing the tip of a guidewire opposite to the arterial wall calcification and finally breaking into the vein with it. The technical success rate was 77% (n = 9), and the limb salvage rate was 67%. Complete wound healing was achieved in 67% of the cases with a median healing time of 4.9 months. As an alternative of this relatively blind technique, Ysa et al3Ysa A. Lobato M. Mikelarena E. Arruabarrena A. Gómez R. Apodaka A. et al.Homemade device to facilitate percutaneous venous arterialization in patients with no-option critical limb ischemia.J Endovasc Ther. 2019; 26: 213-218Crossref Scopus (21) Google Scholar,4Ysa A. Lobato M. Reply to “Regarding: ‘Homemade device to facilitate percutaneous venous arterialization in patients with no-option critical limb ischemia’”.J Endovasc Ther. 2019; 26: 427-428Crossref Scopus (4) Google Scholar introduced the venous arterialization simplified technique (VAST). Based on the gunsight approach, in this maneuver, either a balloon and a snare catheter or two snares are introduced into both the tibial artery and vein, which are then used as the targets of a percutaneous needle puncture. The arteriovenous communication was achieved in all the patients of the study (n = 5) with a limb salvage rate of 75% (median healing time, 20 ± 4 weeks). The percutaneous deep venous foot arterialization (PiPeR) technique5Migliara B. Cappellari T.F. A novel technique to create an arteriovenous fistula during total percutaneous deep foot venous arterialisation using an IVUS guided catheter.Eur J Vasc Endovasc Surg. 2018; 55: 735Abstract Full Text Full Text PDF Scopus (11) Google Scholar reproduces a “LimFlow like” procedure using an intravascular ultrasound-guided catheter (Pioneer Plus; Philips Volcano, San Diego, Calif) to create the arteriovenous communication instead of the dedicated ultrasonic catheter of the LimFlow system. In the study presented by Dr Migliara at Leipzig Interventional Course 2018 (n = 16), he reported a technical success rate of 93.7%, complete wound healing of 26.7%, and limb salvage rate of 66.7%. In summary, percutaneous venous arterialization can successfully be performed using different approaches with limb salvage rates within the range for those reported in the open or hybrid deep venous arterialization literature. We hope these remarks will be of benefit and may complement the goal of the article as being a complete update of the state of the art of this promising procedure. Open, percutaneous, and hybrid deep venous arterialization technique for no-option foot salvageJournal of Vascular SurgeryVol. 71Issue 6PreviewDeep venous arterialization (DVA) is a technique aimed at providing an option for chronic limb-threatening ischemia patients with no options except amputation. In patients with no outflow distal targets permitting bypass, DVA involves creating a connection between a proximal arterial inflow and a distal venous outflow in conjunction with disruption of the vein valves in the foot. This permits blood flow to reach the foot and potentially to resolve rest pain or to assist in healing of a chronic wound. Full-Text PDF Open ArchiveReplyJournal of Vascular SurgeryVol. 71Issue 6PreviewWe very much appreciate the time Drs Ysa and Lobato have taken to read and comment on our article. We agree completely that the percutaneous techniques described in the papers by Gandini et al, Ysa et al, and Migliara and Cappellari are novel and undoubtedly the way in which a number of percutaneous deep venous arterialization procedures are being performed in the United States, given that the LimFlow device (LimFlow SA, Paris, France) is still under review. The LimFlow clinical trial is a multicenter, prospective, single-arm study that is being performed in U.S. Full-Text PDF Open Archive

Keywords amputation, below-knee arteries, chronic limb-threatening ischemia, critical limb ischemia, desert foot, endovascular technique, limb salvage, no-option CLTI, peripheral artery disease, wound healing

Purpose: To present a simple method to avoid favored passage of a guidewire into the profunda femoris artery (PFA) after antegrade puncture of the common femoral artery. Technique: A 6-F conventional introducer sheath with a radiopaque distal marker is placed on the nurse’s table with its side port orientated to the 12 o’clock position. A small (2–2.5 mm) oval fenestration is created on the superior aspect of the sheath about 3 cm from its tip with a size 11 surgical blade. The modified introducer is passed over the angled 0.035-inch guidewire into the PFA and gently retrieved until the tip marker is ~3 cm from the femoral bifurcation. The dilator is removed, and the guidewire is withdrawn to the level of the fenestration, manipulated through it, and advanced further into the superficial femoral artery under fluoroscopic guidance. Conclusion: When repeated passage of the guidewire down the PFA persists despite conventional manipulation of the wire or needle, an on-site modification of the sheath is an easy alternative approach for the catheterization of the superficial femoral artery.

A case of a femoropopliteal recanalization procedure using a new bailout technical maneuver to aid reentry into the true lumen is described. After a failed standard reentry attempt, at the level of the vessel reconstitution in the subintimal space, the guidewire was exchanged for a GooseNeck Snare Kit. A needle was inserted across the target artery, piercing both arterial walls and passing through the snare loop. Once the needle had exited the artery, a wire was inserted and the needle withdrawn. The snare was closed, withdrawn, and the wire externalized through the femoral access. Finally, a catheter was advanced from the antegrade sheath up to the arterial reconstitution. Selective injection at the site of reentry confirmed the intraluminal position, and the procedure was successfully completed from the antegrade sheath.