CTO PCI is currently being performed with high success and acceptable complication rates among various experienced centers in the United States, Europe, and Russia. (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS CTO]; NCT02061436).

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A significant proportion (~ 20%) of patients with complex tibial artery occlusions cannot be treated using a conventional antegrade approach. We report our experience using the retrograde approach for the treatment of complex tibial artery occlusive disease using retrograde pedal/tibial access in 13 limbs from 12 patients. Retrograde pedal/tibial access was achieved in all cases (facilitated by surgical cutdown in one case), and procedural success was achieved in 11 of 13 limbs (85%). Based on this experience, a discussion of clinical and technical aspects of the retrograde pedal/tibial approach is provided, and a new classification for tibial artery occlusive disease is proposed.

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Endovascular therapy for treatment of obstructive disease of the CFA is associated with a high rate of acute technical success. Primary patency rates in the cohort treated for access-site-related complications and thromboembolic disease are excellent and support an endovascular-first approach for this patient subset. Based on lower patency rates, surgical endarterectomy for the treatment of atherosclerotic disease in the CFA remains the gold standard in patients with normal surgical risk.