title: The open retrograde approach as an alternative for failed percutaneous access for difficult below the knee chronic total occlusions-A case series.
abstract: Retrograde puncture via patent pedal vessels can be attempted in failed antegrade approach for infrapopliteal long chronic total occlusion. However in cases where the pedal vessels are unable to be visualized via duplex ultrasonography or fluoroscopy an open approach offers an additional option to a vascular surgeon for successful recanalization. Our case report highlights 3 cases where successful hybrid open retrograde approach was able to achieve recanalization of long chronic total occlusion.
  
  
  METHODS
  The three cases in our series presented with critical limb ischaemia. All three cases had undergone duplex imaging of the affected arterial system. As the antegrade approach to cross the lesion failed a retrograde approach was attempted in all 3 cases. However when the usual modality of retrograde puncture via the use of ultrasound or fluoroscopy failed we proceeded with an open approach.
  
  
  CONCLUSIONS
  Retrograde approach usually offers a better chance of successfully crossing a chronic total occlusion lesion. However puncturing a distal vessel successfully and traversing a catheter or guidewire across proves to be a challenge. An open approach offers an additional pathway for puncturing the target vessel when duplex imaging or fluoroscopic guidance fails.
  
  
  CONCLUSIONS
  Open approach is usually attempted as a last resort by many endovascular surgeons. However procedural time, contrast and radiation usage could have been cut short in cases where the distal target vessels pose a technical challenge for approach via a percutaneous method.
authors.affiliation: Vascular Unit, Changi General Hospital, Singapore. Electronic address: drsara75@gmail.com.
authors.forename: K
authors.initials: K
authors.lastname: Saravana
authors.affiliation: Vascular Unit, Changi General Hospital, Singapore.
authors.forename: Y K
authors.initials: YK
authors.lastname: Tan
authors.affiliation: Vascular Unit, Changi General Hospital, Singapore.
authors.forename: S
authors.initials: S
authors.lastname: Kum
authors.affiliation: Vascular Unit, Changi General Hospital, Singapore.
authors.forename: T Y
authors.initials: TY
authors.lastname: Tang
keywords: Angiography; Chronic total occlusion (CTO); Critical limb ischaemia (CLI); Retrograde approach