Comparison of ante-versus retrograde access for the endovascular treatment of long and calcified, de novo femoropopliteal occlusive lesions

  • Sorin Giusca
  • Micheal Lichtenberg
  • Saskia Hagstotz
  • Christoph Eisenbach
  • Hugo A. Katus
  • Christian Erbel
  • Grigorios KorosoglouEmail author
Original Article


To compare antegrade versus retrograde recanalization, in terms of procedural time, radiation and contrast agent exposure, number and total length of implanted stents and procedural complications, in long and calcified, de novo femoropopliteal occlusions. We performed retrospective matching of prospectively acquired data by lesion length, occlusion length and lesion calcification by the peripheral arterial calcium scoring system (PACSS) score in patients who were referred for endovascular treatment due to symptomatic peripheral artery disease (PAD). Forty-two consecutive patients with antegrade and 23 patients with retrograde after failed antegrade recanalization were identified (mean lesion length = 32.1 ± 6.9 cm; mean occlusion length = 24.6 ± 7.7 cm; PACSS score = 3.25 ± 0.91). 23% of the patients had intermittent claudication, whereas 77% exhibited critical limb ischemia (CLI). Patients who underwent retrograde versus antegrade recanalization required a significantly lower number of stents (0.9 ± 1.0 versus 1.8 ± 1.4, p = 0.01) and a lower total stent length (6.8 ± 8.5 cm versus 11.7 ± 9.9 cm, p < 0.05) in the interest of more extensive coverage of the lesions using drug coated balloons (DCB) (28.5 ± 12.0 cm versus 18.2 ± 16.0 cm, p = 0.01). No re-entry device was required with the retrograde versus 9 of 42 (21%) with the antegrade recanalization group (p = 0.02). The rate of complications due to retrograde puncture was low (one patient with hematoma and one with distal pseudoaneurysm, both managed conservatively). In long and calcified femoropopliteal occlusions, the retrograde approach is associated with a lower number of re-entry devices and stents and with more extensive lesion coverage with DCB, in the interest of costs and possibly long-term patency.

German Clinical Trials Register: DRKS00015277.


Retrograde access Long and calcified occlusive femoropopliteal lesions Pedal puncture Stent placement Atherectomy Drug-coated balloon Dissection re-entry Subintimal Intraluminal recanalization 



Coronary artery disease


Common femoral artery


Critical limb ischemia


Drug coated balloons


Glomerular filtration rate


Highly sensitive troponin T


Peripheral artery disease


Peripheral arterial calcium scoring system


Superficial femoral artery


Transatlantic Intersociety Consensus



No funding was available for our study.

Compliance with ethical standards

Conflict of interest

No conflicts of interests to declare on behalf of all authors of this study.


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Copyright information

© Springer Japan KK, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Cardiology, Vascular Medicine, Pneumology, Gastroenterology and DiabetologyGRN Academic Teaching Hospital WeinheimWeinheimGermany
  2. 2.Department of AngiologyArnsbergGermany
  3. 3.Department of Cardiology, Angiology and PneumologyUniversity Hospital HeidelbergHeidelbergGermany

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