Clinical feasibility of endovascular therapy via trans-ankle intervention: a retrospective single-center study

Clinical feasibility of endovascular therapy via trans-ankle intervention: a retrospective single-center study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical feasibility of endovascular therapy via trans-ankle intervention: a retrospective single-center study Hiromi Miwa, Naoki Hayakawa, Toshiki Tsurumaki, Yasuyuki Tsuchida, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9339018/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Trans-ankle intervention (TAI) through retrograde distal access via below-the-knee and below-the-ankle arteries has been increasingly reported as an alternative approach for the treatment of femoropopliteal (FP) lesions. Although previous studies have described the procedural success of this strategy, its clinical feasibility and postprocedural outcomes remain insufficiently characterized. Methods In this retrospective single-center study, the data of 33 patients with 36 FP lesions who underwent endovascular therapy (EVT) between January 2024 and January 2025 were analyzed. The primary endpoint was procedural success. The secondary endpoints were clinical worsening of lower-limb ischemia within 30 days, 1-year freedom from clinically driven target lesion revascularization (CD-TLR), and procedural complications. The risk of post-procedure access vessel occlusion was also investigated. Results TAI via the anterior tibial artery (ATA) to the dorsalis pedis artery was performed in all patients. Procedural success was achieved in all cases, and the rate of 1-year freedom from CD-TLR was 91.8%. All patients had FP lesions, including three cases up to the iliac artery. 42% was chronic total occlusion, and EVT of the ATA was required in 42% of the cases to establish the access route. No patients showed clinical worsening within 30 days. The risk factors for ATA occlusion were hemodialysis, ATA intervention, and approach via the occluded ATA. Conclusions TAI showed feasible results, especially for FP lesions without serious complications. Although no clinical worsening was observed, an increased risk of postoperative ATA occlusion existed in patients on hemodialysis and those with access site atherosclerosis requiring ATA intervention. However, this limitation may potentially be surmounted by approaching through the occluded ATA. endovascular therapy femoropopliteal artery tibial artery trans-ankle intervention Figures Figure 1 Figure 2 Figure 3 Background Endovascular therapy (EVT) has become a standard treatment for patients with peripheral artery disease (PAD) ( 1 ). There are several approaches for femoropopliteal (FP) artery revascularization. The transfemoral approach (TFA) is the most commonly used. Retrograde tibioperoneal access is a safe option for EVT after antegrade approach failure ( 2 , 3 ). However, it is rare to complete this procedure using a primary retrograde approach. In percutaneous coronary intervention (PCI), one study suggested that compared with the TFA, the transradial approach (TRA) showed reduced mortality and major adverse cardiovascular event rates, as well as improved safety, with reductions in major bleeding and vascular complications ( 4 ). The efficacy and safety of the TRA for PCI have been well established, making it a standard access site. In EVT procedures, the TRA has demonstrated non-inferiority to the TFA, allowing less invasive treatment ( 5 ). However, its application is limited to the treatment of the iliac arteries or the proximal portion of the superficial femoral artery due to the effective length of each device. In recent years, the development of lower-profile guiding sheaths has enabled the use of 6-Fr-equivalent guiding sheaths, even via the tibial arteries. In this context, trans-ankle intervention (TAI) has emerged as a viable minimally invasive treatment option for FP lesions via dorsalis pedis artery (DPA) or anterior tibial artery (ATA) access. TAI has been reported as a successful and effective technique for the treatment of patients with PAD ( 6 ). Using a combination of tibiopedal access and the TRA, a previous study showed a procedural success rate of 99%, even in patients with FP chronic total occlusion (CTO) ( 7 ). However, the clinical course of patients following the use of tibial or other below-the-knee (BTK) arteries as access sites has not been sufficiently reported. In the present study, we evaluated the efficacy and safety of TAI, with particular focus on patient symptoms and the clinical course of the access site. Methods Ethics The study protocol was approved by the ethics committee of Asahi General Hospital, and the study was performed in accordance with the Declaration of Helsinki. The requirement for informed consent was waived because of the retrospective study design, in which existing medical records were used to obtain patient data. However, patients were given the option to opt out of the study. Relevant information regarding the study is available to the public in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects. Patients and study design In this retrospective, single-center cohort study, the data of consecutive patients diagnosed with PAD at Asahi General Hospital between January 2024 and January 2025 were analyzed, including 36 patients who underwent primary TAI for FP lesions (Figure 1). Patients with chronic limb-threatening ischemia (CLTI) and acute limb ischemia were excluded because these conditions are contraindications for TAI. The choice of TAI was determined at the discretion of each operator. Patients were excluded if TAI was considered unfeasible during pre-procedural assessment, defined as the absence of a DPA and an ATA diameter <2 mm on ultrasound, or unsuitability as judged by the operator. EVT procedure Dual antiplatelet therapy, defined as the administration of aspirin and clopidogrel or prasugrel, or antiplatelet and anticoagulant therapy, was used at least 1 month after the procedure. At least one antiplatelet or anticoagulant drug was administered for a minimum of 6 months after the EVT procedure. A 6-Fr guiding sheath (Parent Select 5082 ® ; Medikit, Japan) or a 7-Fr guiding sheath (Parent Pro 60 ® ; Medikit) was inserted into the ipsilateral ATA via the DPA. The puncture site and type of guiding sheath were determined by the ultrasound findings. After guiding sheath insertion, an intravenous heparin bolus (5,000 units) was administered, followed by an infusion of 1,000 units per hour. After 0.014-, 0.018-, and 0.035-inch guidewires were passed through the ATA, the guiding sheath was inserted via the ATA. If the ATA was occluded or stenotic, ATA intervention was performed to insert the guiding sheath prior to FP treatment. Plain old balloon angioplasty (POBA) of the ATA was performed using a 2.5-mm or 3.0-mm balloon. Intravascular ultrasound (IVUS) was used for lesion assessment, if needed. When guidewire passage through the occluded ATA was challenging, IVUS-guided wiring was performed (8). The ATA was then used as an access route after successful guidewire advancement into the proximal true lumen. The guiding sheath was advanced to the popliteal artery, and angiography was performed. When retrograde angiography did not allow adequate assessment of the entire FP segment, a 4-Fr catheter or an aspiration catheter was advanced to the common femoral artery (CFA) after guidewire passage, followed by angiography. Then, 0.014-, 0.018-, or 0.035-inch guidewires were used with a microcatheter or back-up support catheter. A bidirectional approach was used if the conventional single-directional guidewire crossing failed. The bidirectional approach was performed via the ipsilateral CFA, the contralateral CFA, or the TRA. After guidewire passage, pre-dilation was performed using an optimally sized balloon (IVUS- or quantitative vascular angiography-based). The type of balloon (semi-compliant, non-compliant, cutting, or scoring) was at each clinician’s discretion. The drug-coated balloon (DCB) was used after confirming that residual stenosis was <50% and the degree of dissection was less than grade D based on the National Heart, Lung and Blood Institute (NHLBI) criteria (9). Pressure gradient evaluation was performed as required, and pressure gradients 50% residual stenosis or NHLBI grade D or higher dissection was observed after using the DCB, bailout stenting was considered. The necessity for stent use was judged by each clinician. Atherectomy devices require compatibility with a 7-Fr or larger guiding sheath. Therefore, their use was considered only in cases where a 7-Fr guiding sheath could be inserted. Hemostasis of the DPA was achieved using a tape (Astepty ® ; Nichiban, Japan) or a hemostasis band (Bleed Safe ® ; Terumo, Japan). If a stent was placed, at least two antithrombotic drugs were administered for at least 1 month. Data definitions Among the patients with PAD, patients with lower-extremity artery disease were included. Severity was assessed using the Rutherford classification (11). CLTI was defined as a Rutherford class of 4–6. However, for convenience, Rutherford classes 5 and 6 were denoted as CLTI in this study. Clinical worsening included worsening of claudication or pain at rest and formation of new wounds. The status of the ATA was classified as either occluded or open, with stenosis included in the open category. It was evaluated separately for pre-procedural ATA (pre-ATA) and post-procedural ATA (post-ATA). Pre-ATA status was determined based on ultrasound examination, computed tomography (CT), and angiographic findings. Follow-up of the target lesion and post-ATA status was performed by ultrasound examination or CT. Follow-up of the puncture site was performed by ultrasound, Doppler examination, palpation of the DPA, or CT. Outcomes The primary outcome was procedural success. The secondary outcomes included clinical worsening of lower-limb ischemia within 30 days, 1-year clinically driven target lesion revascularization (CD-TLR), and procedural complications. Procedural success was defined as successful recanalization of the target lesion with <30% residual stenosis on final angiography. Clinical follow-up was performed 30 days after EVT with a tolerance of ±2 months, and 12 months after EVT with a tolerance of ±2 months. Clinical events were evaluated by at least two specialists from the Japanese Association of Cardiovascular Intervention and Therapeutics. Statistical analysis Statistical analyses were performed using Stata, version 16 (StataCorp, College Station, TX, US). Normally distributed data were presented as the mean ± standard deviation, while non-normally distributed data were presented as the median (interquartile range). Categorical data are presented as number (percentage). P < 0.05 was considered statistically significant, and 95% confidence intervals (CIs) are reported where appropriate. Based on the hypothesis that post-ATA occlusion contributes to clinical outcomes, we investigated post-ATA occlusion and its risk factors. The association was investigated using a logistic regression model. Univariate analysis was performed using the following factors: ambulant, hemodialysis, coronary artery disease, Rutherford ≥4, PACCS grade ≥3, approach from occluded ATA, intervention to approach ATA Results Patients’ demographic and clinical characteristics Overall, 33 patients underwent EVT and were included in the analysis. Three patients underwent bilateral limb EVT. The patients’ characteristics are summarized in Table 1 . The median age was 75 years. 31 cases (86.1%) were ambulatory and nine (25%) were on hemodialysis. Most of the patients had intermittent claudication, and three cases (8.3%) were classified as Rutherford class 4. In 34 cases (94.4%), the FP artery was the target lesion, and 15 cases (42.0%) were CTO. Table 1 Patients’ demographic and clinical characteristics. Characteristics number Male 33 91.7% Right 21 58.3% Age, median [IQR] 75 [70-81.25] Body mass index 23.3 ± 3.72 Ambulatory 31 86.1% Hypertension 32 88.9% Diabetes mellitus 21 58.3% Dyslipidemia 35 97.2% Smoke history Never smoker 2 5.6% Past smoker 22 61.1% Current smoker 11 30.6% Kidney function Normal 17 47.2% Chronic kidney disease without hemodialysis 10 27.8% Hemodialysis 9 25% Stroke 8 22.2% Coronary artery disease 21 58.3% Congestive heart failure 10 27.8% Atrial fibrillization 5 13.9% Aortic stenosis >moderate 1 4.8% Rutherford classification 2 17 47.2% 3 16 44.4% 4 3 8.3% Medication Aspirin 32 88.9% P2Y12 inhibitor 31 86.1% Cilostazol 5 13.9% Anticoagulant 5 13.9% Statin 26 72.2% Lesion location Iliac artery 3 8.3% Femoral artery 34 94.4% Popliteal artery 4 11.1% Chronic total occlusion 15 42.0% Denovo 24 66.7% Calcium location 19 52.8% PACCS grade 0 10 27.8% 1 4 11.1% 2 3 8.3% 3 7 19.4% 4 12 33.3% IQR, interquartile range; PACCS, peripheral artery calcium scoring system Procedural characteristics The revascularization procedure characteristics are shown in Table 2 . Procedural success was achieved in all cases (100%). Ten cases (27.8%) were approached via the occluded pre-ATA, and 15 (41.7%) required intervention to approach the vessel. The average number of pre-procedural and post-procedural BTK run-off vessels was 2.4 and 2.75, respectively. The median procedure time was 54 minutes. Slow flow was not observed in any case, while distal embolization was observed in three cases (8.3%). Table 2 Procedural characteristics. Characteristics Procedural success 36 100% Approach from occluded ATA 10 27.8% Intervention to approach ATA 15 41.7% Pre- BTK run off (number) average 2.4 0, 1 6 17.1% 2, 3 29 82.9% Post- BTK run off (number) average 2.75 0, 1 1 2.78% 2, 3 35 97.2% Post- approach ATA run off 36 100% Additional antegrade approach (only angiography) 8 ( 4 ) 22.2% Procedure time, min, median [IQR] 54 [16–85] Radiation exposure (TKA) mGy 135 [11.5-216.5] Finalize device Stent 2 5.6% Hybrid therapy 2 5.6% Drug coated balloon 32 88.9% Balloon 1 2.8% Final NHLBI dissection 0, a 28 77.8% b 7 19.4% c 1 2.8% d 0 0% Bail-out stenting 0 0% Jetstream 1 2.8% Crosser 5 13.9% Wingman 9 25.0% Fracking 6 17.1% Intravascular ultrasound use 11 30.6% Slow flow 0 0% Distal embolization 3 8.3% Procedure related complication 0 0% ATA, anterior tibial artery: BTK, below the knee: IQR, interquartile range; TKA, total air karma; NHLBI, National Heart, Lung and Blood Institute. Patient outcomes The clinical outcomes of the patients are shown in Table 3 . No patients showed clinical worsening of lower-limb ischemia within 30 days. The 1-year CD-TLR was 91.8% (Fig. 2 ). Access vessel follow-up was performed using CT or ultrasound, and seven ceses (21.9%) experienced occlusion. Table 3 Clinical outcomes of the patients. Characteristic Mortality (1 year) 2 5.6% Amputation (1 year) 0 0% Clinical worsening (within 30 days) 0 0% Clinical worsening (within 1 year) 1 2.9% Freedom from CD-TLR (within 1 year) 31 91.8% Access vessels (post-procedural ATA) follow up Achieved in 32 cases Open 25 78.1% Occluded 7 21.9% Puncture sites (post-procedural DPA) follow up Achieved in 36 cases Open 34 94.4% Occluded 2 5.6% ATA, anterior tibial artery; CD-TLR, clinically driven target lesion revascularization; DPA, dorsalis pedis artery. Risk factors for post-procedural ATA occlusion The risk factors for post-ATA occlusion were evaluated (Table 4 ). Hemodialysis, pre-ATA status, and ATA intervention were significant risk factors for post-ATA occlusion. Table 4 Risk factors of post-procedural ATA occlusion Ambulant OR [95% CI] p value 0.52 [0.04–6.77] 0.62 Hemodialysis 28.8 [3.23–255.8] 0.003 Coronary artery disease 2.31 [0.37–14.2] 0.37 Rutherford ≥ 4 1.92 [0.15–24.9] 0.62 PACCS grade ≥ 3 2.71 [0.44–16.7] 0.28 Approach from occluded ATA 10.0 [1.48–67.6] 0.018 Intervention to approach ATA - < 0.001 ATA, anterior tibial artery; CI, confidence interval; OR, odds ratio; PACCS, peripheral artery calcium scoring system. The distribution of risk factors for post-procedural ATA occlusion is shown in Fig. 3 . Among patients on hemodialysis, post-ATA occlusion occurred in five of seven (71.4%) (Fig. 3 A, 3 B. All of these patients underwent ATA POBA. In contrast, the two patients in whom post-ATA occlusion did not occur were approached via the patent pre-ATA and did not undergo ATA POBA. The open pre-ATA approach demonstrated two cases of occlusion, both involving patients on hemodialysis requiring ATA POBA (Fig. 3 C). Meanwhile, the occluded pre-ATA approach maintained patency in half of the patients postoperatively. For patients in whom ATA POBA was not performed, post-ATA remained patent in all patients (Fig. 3 D). When POBA was performed, the post-ATA became occluded in 7 of 12 cases; all of these were either patients on hemodialysis or patients in whom the occluded pre-ATA was used as the approach site. Discussion In this study, procedural success was achieved in all patients, and the 1-year freedom from CD-TLR was 91.8%, showing feasible results compared with a previous FP treatment study ( 12 ). In this study, 42% of the patients had CTO of the FP lesion, suggesting that this approach site may be effective even for treating complex lesions. The procedure time, including access route establishment, was 54 minutes, which was considered acceptable. The high success rate of this procedure is believed to have been achieved because the treatment options were not limited and the 6-Fr guiding sheath was inserted. Stent deployment, insertion of specific systems, and IVUS-guided parallel wiring were performed with less difficulty. Debulking device insertion was challenging as it required a 7-Fr guiding sheath; however, the only patient treated with the atherectomy device (Jetstream®; Boston Scientific, USA) achieved success, with favorable clinical outcomes and persistent post-ATA patency. The 1-year CD-TLR rate was also acceptable. This finding suggests that, even with TAI, there were minimal device-related limitations in FP treatment, potentially allowing intervention with comparable quality to that achieved via the TFA. In fact, a 6-Fr guiding sheath (or larger) was successfully inserted in all cases, enabling treatment with virtually no device restrictions, such as DCBs and stents. The insertion of balloons and stents is possible up to the ipsilateral iliac artery. As demonstrated by the inclusion of three patients with treatment of the iliac artery in this study, treatment from the ipsilateral iliac artery to BTK arteries is feasible with TAI. However, as TAI is retrograde, it has the disadvantage of difficulty in angiography. For occlusive FP lesions, an antegrade approach was used when necessary. Antegrade sheath insertion was performed in eight patients, with four of these used solely for angiography. Combining this with the TRA enabled a minimally invasive procedure, avoiding femoral artery puncture. The high success rate of unidirectional wiring, even in CTO procedures, was likely attributable to the adjunctive use of IVUS-guided wiring. Procedure-related complications included distal embolism in 8% of cases; however, all events were successfully managed with bailout treatment during the procedure, and no final slow-flow phenomenon was observed. No bleeding complications, including those related to the access site, or cerebrovascular events, such as stroke, were recorded. These findings suggest that TAI, similar to the TRA, is associated with a low incidence of procedural complications, including access site-related events, and may represent a minimally invasive treatment strategy. No patients demonstrated clinical worsening of lower-limb ischemia within 30 days, suggesting that this access site is acceptable. However, asymptomatic worsening could not be detected. Therefore, we assessed the risk of post-ATA occlusion, which could lead to lower-limb ischemia. Hemodialysis, pre-ATA status, and ATA intervention were significant risk factors for post-ATA occlusion. Patients on hemodialysis and patients with advanced peripheral atherosclerosis who require POBA for guiding sheath insertion potentially carry a risk of further atherosclerotic progression. Therefore, the possibility of natural progression remains, and whether TAI should be used as an access site should be carefully considered. In patients on hemodialysis undergoing PCI, the TRA shows a lower risk of access site bleeding and in-hospital mortality than the TFA, suggesting that the radial artery is a safe access site ( 13 , 14 ). This finding likely reflects the underlying clinical background of patients on hemodialysis, who are at an increased risk of bleeding and are more prone to access site complications. TAI carries a risk of occlusion due to its approach via small-diameter vessels, but it holds potential for reducing bleeding complications. If the pre-ATA is occluded, there is a risk of re-occlusion. This is because it is difficult to maintain patency after BTK artery treatment ( 15 ). However, post-ATA re-occlusion is unlikely to be a significant problem. This is because when an ATA that was already occluded is used as an access route, any subsequent re-occlusion would simply return the vessel to its pre-procedural state. Therefore, using the occluded pre-ATA as an access site is reasonable. Using the TRA for PCI, studies have also demonstrated the utility of trans occluded radial access ( 16 ). Although it is technically challenging, it is a feasible option, even for patients with CLTI ( 17 ). IVUS-guided wiring is an effective technique for BTK CTO treatment ( 8 ). Even in patients with unstable hemodynamics and limited access sites, hemostatic procedures via the occluded ATA can be performed safely using IVUS-guided wiring ( 18 ). However, TAI in patients with CLTI remains controversial. One study showed that below-the-ankle distal puncture in stenotic arteries may cause puncture site occlusion before wound healing ( 19 ). The outer diameter of the sheath used in this study was 2.4 mm, suggesting the risk of puncture site occlusion if the DPA was small. Another study showed that using the approach from a single remaining BTK vessel showed feasible and safe results, and access vessel occlusion occurred in 9 of 314 patients ( 20 ). The application of TAI in patients with CLTI should be carefully considered. This study had several limitations. It was a retrospective, non-randomized, single-center study with a small sample size, so the results may not be generalizable. The choice of access strategy, the timing of conversion to the bidirectional approach, and device selection were at the operator’s discretion, and no standardized protocol was used. Patient selection was based on the operator’s judgment of TAI feasibility, which may have introduced selection bias. Furthermore, all angiographic findings and clinical outcomes were assessed on site, without adjudication by an independent core laboratory or clinical events committee. Therefore, future large-scale prospective studies are warranted to validate our findings. Conclusions TAI was an effective EVT approach for FP lesions. Although no clinical worsening was observed, the risk of post-ATA occlusion was increased in patients on hemodialysis and access site atherosclerotic pre-ATA requiring POBA. However, this limitation may potentially be surmounted by approaching from the occluded pre-ATA. Abbreviations ATA, anterior tibial artery; BTK, below-the-knee; CD-TLR, clinically driven target lesion re-stenosis; CFA, common femoral artery; CI, confidence interval; CLTI, chronic limb-threatening ischemia; CT, computed tomography; CTO, chronic total occlusion; DAPT, dual antipatelet therapy; DCB, drug-coated balloon; DPA, dorsal pedalis artery; EVT, endovascular therapy; FP, femoropopliteal; GS, guiding sheath; IVUS, intravascular ultrasound; NHLBI, National Heart, Lung and Blood Institute; PACCS, peripheral artery calcium scoring system; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; POBA, plain old balloon angioplasty; post-ATA, post-procedural anterior tibial artery; pre-ATA, pre-procedural anterior tibial artery; TAI, trans-ankle intervention; TFA, transfemoral approach; TRA, transradial approach. 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Uyanık SA, Öğüşlü U, Yılmaz B, Çevik H, Atlı E, Gümüş B. Retrograde Pedal Access via Occluded Arteries in Endovascular Treatment of Critical Limb Ischemia. J Vasc Interv Radiol. 2021;32(2):164-72. Miwa H, Hayakawa N, Tsuchida Y, Ichihara S, Hirano S, Maruta S, et al. An effective method for percutaneous hemostasis of femoral artery by endovascular balloon occlusion via the occluded dorsal pedalis artery approach in a patient with restricted access site. SAGE Open Med Case Rep. 2025;13:2050313x251364131. Iwata S, Tan M, Miwa T, Sasaki W, Urasawa K. Vascular and wound healing outcomes after puncture of small or stenotic inframalleolar arteries in patients with chronic limb-threatening ischemia. J Vasc Surg. 2025;82(5):1736-44.e1. Siu HK, Schultz E, LeBrun S, Liou M, Kwan TW. Safety of Retrograde Tibial-Pedal Access and Intervention in Patients with Single Remaining Non-Occluded Infra-Popliteal Runoff Artery. J Cardiovasc Dev Dis. 2023;10(11). Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 Apr, 2026 Reviewers invited by journal 13 Apr, 2026 Editor assigned by journal 10 Apr, 2026 First submitted to journal 09 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9339018","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":622379062,"identity":"2e67afc6-cf78-4bbe-8d2f-7a87ed7d8163","order_by":0,"name":"Hiromi Miwa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYBACA2YwCeEcYGCwAVKMjQeI13KAIQ2kpQG/FhTeAYbDMOtwA3N23oePbhQw5DHwH354+EPFebu17YeBttTYROPSYtnMbmycY8BQzCCRZnDgwJnbydvOJAK1HEvLbcDlsMNsbNJALYkNEgwGBw623U42OwDUwthwmAgt/Mc/ALWcSzY7/5BYLQw5IFsO2JndIGwLM9AvEoltEjkFB86cSU4wuwG0JQGfX84fY3yc88cmsZ//+OYPFRV29mbn0x8++FBjg1MLFEgwsEFZiWCVCfiVowJ7UhSPglEwCkbByAAA0/hhOKLynLoAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0005-4785-7452","institution":"Asahi general hospital","correspondingAuthor":true,"prefix":"","firstName":"Hiromi","middleName":"","lastName":"Miwa","suffix":""},{"id":622379063,"identity":"22592ff5-3d66-4448-b98b-fdc04574709b","order_by":1,"name":"Naoki Hayakawa","email":"","orcid":"","institution":"Asahi general hospital","correspondingAuthor":false,"prefix":"","firstName":"Naoki","middleName":"","lastName":"Hayakawa","suffix":""},{"id":622379064,"identity":"15d9c59f-e940-4802-a8e2-ed5f52d5222b","order_by":2,"name":"Toshiki Tsurumaki","email":"","orcid":"","institution":"Asahi general hospital","correspondingAuthor":false,"prefix":"","firstName":"Toshiki","middleName":"","lastName":"Tsurumaki","suffix":""},{"id":622379065,"identity":"dfd79456-2bcc-4f3d-8cf6-67fb6d34aa1f","order_by":3,"name":"Yasuyuki Tsuchida","email":"","orcid":"","institution":"Asahi general hospital","correspondingAuthor":false,"prefix":"","firstName":"Yasuyuki","middleName":"","lastName":"Tsuchida","suffix":""},{"id":622379066,"identity":"56ce2fb2-e136-4151-aafa-5aba1e39a14b","order_by":4,"name":"Masanao Inoue","email":"","orcid":"","institution":"Asahi general hospital","correspondingAuthor":false,"prefix":"","firstName":"Masanao","middleName":"","lastName":"Inoue","suffix":""},{"id":622379067,"identity":"1f5fee45-7def-41b5-9ba9-78d2ad6858d6","order_by":5,"name":"Shinya Ichihara","email":"","orcid":"","institution":"Asahi general hospital","correspondingAuthor":false,"prefix":"","firstName":"Shinya","middleName":"","lastName":"Ichihara","suffix":""},{"id":622379068,"identity":"f8e38bf0-ead9-4ad5-b9c3-e00246ef2280","order_by":6,"name":"Shunichi Kushida","email":"","orcid":"","institution":"Asahi general hospital","correspondingAuthor":false,"prefix":"","firstName":"Shunichi","middleName":"","lastName":"Kushida","suffix":""}],"badges":[],"createdAt":"2026-04-07 03:43:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9339018/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9339018/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107499860,"identity":"9f71cc96-5e3e-44a5-a9ff-023935be7ca2","added_by":"auto","created_at":"2026-04-22 05:43:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30812,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flowchart.\u003c/p\u003e\n\u003cp\u003eEVT, endovascular therapy; TAI, trans-ankle intervention.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9339018/v1/acb018d7f6430965f677e816.png"},{"id":107499861,"identity":"d5c2703c-a805-4623-9c7e-f41e72add7b1","added_by":"auto","created_at":"2026-04-22 05:43:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":29979,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier curves of freedom from CD-TLR.\u003c/p\u003e\n\u003cp\u003eCD-TLR, clinically driven target lesion revascularization.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9339018/v1/8f7804ca5b7c367c4326c0ef.png"},{"id":107499862,"identity":"b9904c3e-38ea-487e-b532-895fff413ead","added_by":"auto","created_at":"2026-04-22 05:43:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":56536,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of risk factors for post-procedural ATA occlusion. Hemodialysis (a), pre-procedural ATA status (b), and ATA intervention (c) were significant risk factors for post-procedural ATA occlusion. (d) All post-procedural ATA occlusion cases (patients 1–7) and all patients on hemodialysis are shown. Patients 8 and 9 were on hemodialysis, and post-procedural ATA patency was maintained. HD, hemodialysis; ATA, anterior tibial artery; POBA, plain old balloon angioplasty.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9339018/v1/431fb707825978e9eb1a6771.png"},{"id":108180794,"identity":"3aa24d1a-a706-4938-b01a-d47da8d919ea","added_by":"auto","created_at":"2026-04-30 08:53:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":436964,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9339018/v1/6a9bc2c7-fa7f-49c0-b2d8-a431ebf5bfbe.pdf"}],"financialInterests":"","formattedTitle":"Clinical feasibility of endovascular therapy via trans-ankle intervention: a retrospective single-center study","fulltext":[{"header":"Background","content":"\u003cp\u003eEndovascular therapy (EVT) has become a standard treatment for patients with peripheral artery disease (PAD) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). There are several approaches for femoropopliteal (FP) artery revascularization. The transfemoral approach (TFA) is the most commonly used. Retrograde tibioperoneal access is a safe option for EVT after antegrade approach failure (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, it is rare to complete this procedure using a primary retrograde approach. In percutaneous coronary intervention (PCI), one study suggested that compared with the TFA, the transradial approach (TRA) showed reduced mortality and major adverse cardiovascular event rates, as well as improved safety, with reductions in major bleeding and vascular complications (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The efficacy and safety of the TRA for PCI have been well established, making it a standard access site. In EVT procedures, the TRA has demonstrated non-inferiority to the TFA, allowing less invasive treatment (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, its application is limited to the treatment of the iliac arteries or the proximal portion of the superficial femoral artery due to the effective length of each device.\u003c/p\u003e \u003cp\u003eIn recent years, the development of lower-profile guiding sheaths has enabled the use of 6-Fr-equivalent guiding sheaths, even via the tibial arteries. In this context, trans-ankle intervention (TAI) has emerged as a viable minimally invasive treatment option for FP lesions via dorsalis pedis artery (DPA) or anterior tibial artery (ATA) access. TAI has been reported as a successful and effective technique for the treatment of patients with PAD (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Using a combination of tibiopedal access and the TRA, a previous study showed a procedural success rate of 99%, even in patients with FP chronic total occlusion (CTO) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, the clinical course of patients following the use of tibial or other below-the-knee (BTK) arteries as access sites has not been sufficiently reported.\u003c/p\u003e \u003cp\u003eIn the present study, we evaluated the efficacy and safety of TAI, with particular focus on patient symptoms and the clinical course of the access site.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the ethics committee of Asahi General Hospital, and the study was performed in accordance with the Declaration of Helsinki. The requirement for informed consent was waived because of the retrospective study design, in which existing medical records were used to obtain patient data. However, patients were given the option to opt out of the study. Relevant information regarding the study is available to the public in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePatients and study design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective, single-center cohort study, the data of consecutive patients diagnosed with PAD at Asahi General Hospital between January 2024 and January 2025 were analyzed, including 36 patients who underwent primary TAI for FP lesions (Figure 1). Patients with chronic limb-threatening ischemia (CLTI) and acute limb ischemia were excluded because these conditions are contraindications for TAI. The choice of TAI was determined at the discretion of each operator. Patients were excluded if TAI was considered unfeasible during pre-procedural assessment, defined as the absence of a DPA and an ATA diameter \u0026lt;2 mm on ultrasound, or unsuitability as judged by the operator.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEVT procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDual antiplatelet therapy, defined as the administration of aspirin and clopidogrel or prasugrel, or antiplatelet and anticoagulant therapy, was used at least 1 month after the procedure. At least one antiplatelet or anticoagulant drug was administered for a minimum of 6 months after the EVT procedure.\u003c/p\u003e\n\u003cp\u003eA 6-Fr guiding sheath (Parent Select 5082\u003csup\u003e\u0026reg;\u003c/sup\u003e; Medikit, Japan) or a 7-Fr guiding sheath (Parent Pro 60\u003csup\u003e\u0026reg;\u003c/sup\u003e; Medikit) was inserted into the ipsilateral ATA via the DPA. The puncture site and type of guiding sheath were determined by the ultrasound findings. After guiding sheath insertion, an intravenous heparin bolus (5,000 units) was administered, followed by an infusion of 1,000 units per hour. After 0.014-, 0.018-, and 0.035-inch guidewires were passed through the ATA, the guiding sheath was inserted via the ATA. If the ATA was occluded or stenotic, ATA intervention was performed to insert the guiding sheath prior to FP treatment. Plain old balloon angioplasty (POBA) of the ATA was performed using a 2.5-mm or 3.0-mm balloon. Intravascular ultrasound (IVUS) was used for lesion assessment, if needed. When guidewire passage through the occluded ATA was challenging, IVUS-guided wiring was performed (8). The ATA was then used as an access route after successful guidewire advancement into the proximal true lumen.\u003c/p\u003e\n\u003cp\u003eThe guiding sheath was advanced to the popliteal artery, and angiography was performed. When retrograde angiography did not allow adequate assessment of the entire FP segment, a 4-Fr catheter or an aspiration catheter was advanced to the common femoral artery (CFA) after guidewire passage, followed by angiography. Then, 0.014-, 0.018-, or 0.035-inch guidewires were used with a microcatheter or back-up support catheter. A bidirectional approach was used if the conventional single-directional guidewire crossing failed. The bidirectional approach was performed via the ipsilateral CFA, the contralateral CFA, or the TRA. After guidewire passage, pre-dilation was performed using an optimally sized balloon (IVUS- or quantitative vascular angiography-based). The type of balloon (semi-compliant, non-compliant, cutting, or scoring) was at each clinician\u0026rsquo;s discretion. The drug-coated balloon (DCB) was used after confirming that residual stenosis was \u0026lt;50% and the degree of dissection was less than grade D based on the National Heart, Lung and Blood Institute (NHLBI) criteria (9). Pressure gradient evaluation was performed as required, and pressure gradients \u0026lt;10 mmHg were defined as significant stenosis (10). After successful lesion preparation, the target lesion was fully covered by the DCB. If \u0026gt;50% residual stenosis or NHLBI grade D or higher dissection was observed after using the DCB, bailout stenting was considered. The necessity for stent use was judged by each clinician. Atherectomy devices require compatibility with a 7-Fr or larger guiding sheath. Therefore, their use was considered only in cases where a 7-Fr guiding sheath could be inserted. Hemostasis of the DPA was achieved using a tape (Astepty\u003csup\u003e\u0026reg;\u003c/sup\u003e; Nichiban, Japan) or a hemostasis band (Bleed Safe\u003csup\u003e\u0026reg;\u003c/sup\u003e; Terumo, Japan). If a stent was placed, at least two antithrombotic drugs were administered for at least 1 month.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eData definitions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the patients with PAD, patients with lower-extremity artery disease were included. Severity was assessed using the Rutherford classification (11). CLTI was defined as a Rutherford class of 4\u0026ndash;6. However, for convenience, Rutherford classes 5 and 6 were denoted as CLTI in this study. Clinical worsening included worsening of claudication or pain at rest and formation of new wounds. The status of the ATA was classified as either occluded or open, with stenosis included in the open category. It was evaluated separately for pre-procedural ATA (pre-ATA) and post-procedural ATA (post-ATA). Pre-ATA status was determined based on ultrasound examination, computed tomography (CT), and angiographic findings. Follow-up of the target lesion and post-ATA status was performed by ultrasound examination or CT. Follow-up of the puncture site was performed by ultrasound, Doppler examination, palpation of the DPA, or CT.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was procedural success. The secondary outcomes included clinical worsening of lower-limb ischemia within 30 days, 1-year clinically driven target lesion revascularization (CD-TLR), and procedural complications. Procedural success was defined as successful recanalization of the target lesion with\u0026thinsp;\u0026lt;30% residual stenosis on final angiography. Clinical follow-up was performed 30 days after EVT with a tolerance of \u0026plusmn;2 months, and 12 months after EVT with a tolerance of \u0026plusmn;2 months. Clinical events were evaluated by at least two specialists from the Japanese Association of Cardiovascular Intervention and Therapeutics. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using Stata, version 16 (StataCorp, College Station, TX, US). Normally distributed data were presented as the mean \u0026plusmn; standard deviation, while non-normally distributed data were presented as the median (interquartile range). Categorical data are presented as number (percentage). P \u0026lt; 0.05 was considered statistically significant, and 95% confidence intervals (CIs) are reported where appropriate. Based on the hypothesis that post-ATA occlusion contributes to clinical outcomes, we investigated post-ATA occlusion and its risk factors. The association was investigated using a logistic regression model. Univariate analysis was performed using the following factors: ambulant, hemodialysis, coronary artery disease, Rutherford \u0026ge;4, PACCS grade \u0026ge;3, approach from occluded ATA, intervention to approach ATA\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; demographic and clinical characteristics\u003c/h2\u003e \u003cp\u003eOverall, 33 patients underwent EVT and were included in the analysis. Three patients underwent bilateral limb EVT. The patients\u0026rsquo; characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The median age was 75 years. 31 cases (86.1%) were ambulatory and nine (25%) were on hemodialysis. Most of the patients had intermittent claudication, and three cases (8.3%) were classified as Rutherford class 4. In 34 cases (94.4%), the FP artery was the target lesion, and 15 cases (42.0%) were CTO.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients\u0026rsquo; demographic and clinical characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003enumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e75 [70-81.25]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e23.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmbulatory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoke history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease without hemodialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemodialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCongestive heart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic stenosis \u0026gt;moderate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRutherford classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspirin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP2Y12 inhibitor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCilostazol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnticoagulant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesion location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIliac artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemoral artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePopliteal artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic total occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDenovo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcium location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACCS grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eIQR, interquartile range; PACCS, peripheral artery calcium scoring system\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eProcedural characteristics\u003c/h2\u003e \u003cp\u003eThe revascularization procedure characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Procedural success was achieved in all cases (100%). Ten cases (27.8%) were approached via the occluded pre-ATA, and 15 (41.7%) required intervention to approach the vessel. The average number of pre-procedural and post-procedural BTK run-off vessels was 2.4 and 2.75, respectively. The median procedure time was 54 minutes. Slow flow was not observed in any case, while distal embolization was observed in three cases (8.3%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProcedural characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedural success\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach from occluded ATA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention to approach ATA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre- BTK run off (number)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0, 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2, 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost- BTK run off (number)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0, 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.78%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2, 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost- approach ATA run off\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdditional antegrade approach (only angiography)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure time, min, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e54 [16\u0026ndash;85]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation exposure (TKA) mGy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e135 [11.5-216.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinalize device\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHybrid therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrug coated balloon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalloon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal NHLBI dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0, a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ec\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBail-out stenting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJetstream\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCrosser\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWingman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntravascular ultrasound use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlow flow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal embolization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure related complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eATA, anterior tibial artery: BTK, below the knee: IQR, interquartile range; TKA, total air karma; NHLBI, National Heart, Lung and Blood Institute.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePatient outcomes\u003c/h2\u003e \u003cp\u003eThe clinical outcomes of the patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. No patients showed clinical worsening of lower-limb ischemia within 30 days. The 1-year CD-TLR was 91.8% (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Access vessel follow-up was performed using CT or ultrasound, and seven ceses (21.9%) experienced occlusion.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical outcomes of the patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmputation (1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical worsening (within 30 days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical worsening (within 1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFreedom from CD-TLR (within 1 year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccess vessels (post-procedural ATA) follow up\u003c/p\u003e \u003cp\u003eAchieved in 32 cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccluded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuncture sites (post-procedural DPA) follow up\u003c/p\u003e \u003cp\u003eAchieved in 36 cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccluded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eATA, anterior tibial artery; CD-TLR, clinically driven target lesion revascularization; DPA, dorsalis pedis artery.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRisk factors for post-procedural ATA occlusion\u003c/h2\u003e \u003cp\u003eThe risk factors for post-ATA occlusion were evaluated (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Hemodialysis, pre-ATA status, and ATA intervention were significant risk factors for post-ATA occlusion.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factors of post-procedural ATA occlusion\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAmbulant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR [95% CI]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.52 [0.04\u0026ndash;6.77]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemodialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.8 [3.23\u0026ndash;255.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary artery disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.31 [0.37\u0026ndash;14.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRutherford\u0026thinsp;\u0026ge;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.92 [0.15\u0026ndash;24.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACCS grade\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.71 [0.44\u0026ndash;16.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproach from occluded ATA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0 [1.48\u0026ndash;67.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntervention to approach ATA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eATA, anterior tibial artery; CI, confidence interval; OR, odds ratio; PACCS, peripheral artery calcium scoring system.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe distribution of risk factors for post-procedural ATA occlusion is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Among patients on hemodialysis, post-ATA occlusion occurred in five of seven (71.4%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB. All of these patients underwent ATA POBA. In contrast, the two patients in whom post-ATA occlusion did not occur were approached via the patent pre-ATA and did not undergo ATA POBA. The open pre-ATA approach demonstrated two cases of occlusion, both involving patients on hemodialysis requiring ATA POBA (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). Meanwhile, the occluded pre-ATA approach maintained patency in half of the patients postoperatively. For patients in whom ATA POBA was not performed, post-ATA remained patent in all patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD). When POBA was performed, the post-ATA became occluded in 7 of 12 cases; all of these were either patients on hemodialysis or patients in whom the occluded pre-ATA was used as the approach site.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, procedural success was achieved in all patients, and the 1-year freedom from CD-TLR was 91.8%, showing feasible results compared with a previous FP treatment study (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In this study, 42% of the patients had CTO of the FP lesion, suggesting that this approach site may be effective even for treating complex lesions. The procedure time, including access route establishment, was 54 minutes, which was considered acceptable. The high success rate of this procedure is believed to have been achieved because the treatment options were not limited and the 6-Fr guiding sheath was inserted. Stent deployment, insertion of specific systems, and IVUS-guided parallel wiring were performed with less difficulty. Debulking device insertion was challenging as it required a 7-Fr guiding sheath; however, the only patient treated with the atherectomy device (Jetstream\u0026reg;; Boston Scientific, USA) achieved success, with favorable clinical outcomes and persistent post-ATA patency. The 1-year CD-TLR rate was also acceptable. This finding suggests that, even with TAI, there were minimal device-related limitations in FP treatment, potentially allowing intervention with comparable quality to that achieved via the TFA. In fact, a 6-Fr guiding sheath (or larger) was successfully inserted in all cases, enabling treatment with virtually no device restrictions, such as DCBs and stents.\u003c/p\u003e \u003cp\u003eThe insertion of balloons and stents is possible up to the ipsilateral iliac artery. As demonstrated by the inclusion of three patients with treatment of the iliac artery in this study, treatment from the ipsilateral iliac artery to BTK arteries is feasible with TAI. However, as TAI is retrograde, it has the disadvantage of difficulty in angiography. For occlusive FP lesions, an antegrade approach was used when necessary. Antegrade sheath insertion was performed in eight patients, with four of these used solely for angiography. Combining this with the TRA enabled a minimally invasive procedure, avoiding femoral artery puncture. The high success rate of unidirectional wiring, even in CTO procedures, was likely attributable to the adjunctive use of IVUS-guided wiring.\u003c/p\u003e \u003cp\u003eProcedure-related complications included distal embolism in 8% of cases; however, all events were successfully managed with bailout treatment during the procedure, and no final slow-flow phenomenon was observed. No bleeding complications, including those related to the access site, or cerebrovascular events, such as stroke, were recorded. These findings suggest that TAI, similar to the TRA, is associated with a low incidence of procedural complications, including access site-related events, and may represent a minimally invasive treatment strategy.\u003c/p\u003e \u003cp\u003eNo patients demonstrated clinical worsening of lower-limb ischemia within 30 days, suggesting that this access site is acceptable. However, asymptomatic worsening could not be detected. Therefore, we assessed the risk of post-ATA occlusion, which could lead to lower-limb ischemia. Hemodialysis, pre-ATA status, and ATA intervention were significant risk factors for post-ATA occlusion. Patients on hemodialysis and patients with advanced peripheral atherosclerosis who require POBA for guiding sheath insertion potentially carry a risk of further atherosclerotic progression. Therefore, the possibility of natural progression remains, and whether TAI should be used as an access site should be carefully considered. In patients on hemodialysis undergoing PCI, the TRA shows a lower risk of access site bleeding and in-hospital mortality than the TFA, suggesting that the radial artery is a safe access site (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This finding likely reflects the underlying clinical background of patients on hemodialysis, who are at an increased risk of bleeding and are more prone to access site complications. TAI carries a risk of occlusion due to its approach via small-diameter vessels, but it holds potential for reducing bleeding complications.\u003c/p\u003e \u003cp\u003eIf the pre-ATA is occluded, there is a risk of re-occlusion. This is because it is difficult to maintain patency after BTK artery treatment (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, post-ATA re-occlusion is unlikely to be a significant problem. This is because when an ATA that was already occluded is used as an access route, any subsequent re-occlusion would simply return the vessel to its pre-procedural state. Therefore, using the occluded pre-ATA as an access site is reasonable. Using the TRA for PCI, studies have also demonstrated the utility of trans occluded radial access (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Although it is technically challenging, it is a feasible option, even for patients with CLTI (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). IVUS-guided wiring is an effective technique for BTK CTO treatment (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Even in patients with unstable hemodynamics and limited access sites, hemostatic procedures via the occluded ATA can be performed safely using IVUS-guided wiring (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, TAI in patients with CLTI remains controversial. One study showed that below-the-ankle distal puncture in stenotic arteries may cause puncture site occlusion before wound healing (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The outer diameter of the sheath used in this study was 2.4 mm, suggesting the risk of puncture site occlusion if the DPA was small. Another study showed that using the approach from a single remaining BTK vessel showed feasible and safe results, and access vessel occlusion occurred in 9 of 314 patients (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The application of TAI in patients with CLTI should be carefully considered.\u003c/p\u003e \u003cp\u003eThis study had several limitations. It was a retrospective, non-randomized, single-center study with a small sample size, so the results may not be generalizable. The choice of access strategy, the timing of conversion to the bidirectional approach, and device selection were at the operator\u0026rsquo;s discretion, and no standardized protocol was used. Patient selection was based on the operator\u0026rsquo;s judgment of TAI feasibility, which may have introduced selection bias. Furthermore, all angiographic findings and clinical outcomes were assessed on site, without adjudication by an independent core laboratory or clinical events committee. Therefore, future large-scale prospective studies are warranted to validate our findings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTAI was an effective EVT approach for FP lesions. Although no clinical worsening was observed, the risk of post-ATA occlusion was increased in patients on hemodialysis and access site atherosclerotic pre-ATA requiring POBA. However, this limitation may potentially be surmounted by approaching from the occluded pre-ATA.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eATA, anterior tibial artery; BTK, below-the-knee; CD-TLR, clinically driven target lesion re-stenosis; CFA, common femoral artery; CI, confidence interval; CLTI, chronic limb-threatening ischemia; CT, computed tomography; CTO, chronic total occlusion; DAPT, dual antipatelet therapy; DCB, drug-coated balloon; DPA, dorsal pedalis artery; EVT, endovascular therapy; FP, femoropopliteal; GS, guiding sheath; IVUS, intravascular ultrasound; NHLBI, National Heart, Lung and Blood Institute; PACCS, peripheral artery calcium scoring system; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; POBA, plain old balloon angioplasty; post-ATA, post-procedural anterior tibial artery; pre-ATA, pre-procedural anterior tibial artery; TAI, trans-ankle intervention; TFA, transfemoral approach; TRA, transradial approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(24):e1313-e410.\u003c/li\u003e\n\u003cli\u003eSchmidt A, Bausback Y, Piorkowski M, Wittig T, Banning-Eichenseer U, Thiele H, et al. Retrograde Tibioperoneal Access for Complex Infrainguinal Occlusions: Short- and Long-Term Outcomes of 554 Endovascular Interventions. JACC Cardiovasc Interv. 2019;12(17):1714-26.\u003c/li\u003e\n\u003cli\u003eGiannopoulos S, Palena LM, Armstrong EJ. Technical Success and Complication Rates of Retrograde Arterial Access for Endovascular Therapy for Critical Limb Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2021;61(2):270-9.\u003c/li\u003e\n\u003cli\u003eFerrante G, Rao SV, J\u0026uuml;ni P, Da Costa BR, Reimers B, Condorelli G, et al. Radial Versus Femoral Access for Coronary Interventions Across the Entire Spectrum of Patients With Coronary Artery Disease: A Meta-Analysis of Randomized Trials. JACC Cardiovasc Interv. 2016;9(14):1419-34.\u003c/li\u003e\n\u003cli\u003eIida O, Takahara M, Fujihara M, Higashino N, Hayakawa N, Horie K, et al. Clinical Outcomes of Transradial vs Nontransradial Aortoiliac Endovascular Therapy. JACC Cardiovasc Interv. 2024;17(16):1891-901.\u003c/li\u003e\n\u003cli\u003eMustapha JA, Saab F, McGoff T, Heaney C, Diaz-Sandoval L, Sevensma M, et al. Tibio-pedal arterial minimally invasive retrograde revascularization in patients with advanced peripheral vascular disease: the TAMI technique, original case series. Catheter Cardiovasc Interv. 2014;83(6):987-94.\u003c/li\u003e\n\u003cli\u003eHtun WW, Kyaw H, Aung YL, Maw M, Kwan T. Primary Retrograde Tibio-Pedal Approach for Endovascular Intervention of Femoropopliteal Disease with Chronic Total Occlusion. Cardiovasc Revasc Med. 2020;21(2):171-5.\u003c/li\u003e\n\u003cli\u003eHayakawa N, Kodera S, Hirano S, Arakawa M, Inoguchi Y, Kanda J. An AnteOwl WR intravascular ultrasound-guided parallel wiring technique for chronic total occlusion of below-the-knee arteries. CVIR Endovasc. 2022;5(1):18.\u003c/li\u003e\n\u003cli\u003eFeldman DN, Armstrong EJ, Aronow HD, Gigliotti OS, Jaff MR, Klein AJ, et al. SCAI consensus guidelines for device selection in femoral-popliteal arterial interventions. Catheter Cardiovasc Interv. 2018;92(1):124-40.\u003c/li\u003e\n\u003cli\u003eTepe G, Laird J, Schneider P, Brodmann M, Krishnan P, Micari A, et al. Drug-coated balloon versus standard percutaneous transluminal angioplasty for the treatment of superficial femoral and popliteal peripheral artery disease: 12-month results from the IN.PACT SFA randomized trial. Circulation. 2015;131(5):495-502.\u003c/li\u003e\n\u003cli\u003eRutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. 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SAGE Open Med Case Rep. 2025;13:2050313x251364131.\u003c/li\u003e\n\u003cli\u003eIwata S, Tan M, Miwa T, Sasaki W, Urasawa K. Vascular and wound healing outcomes after puncture of small or stenotic inframalleolar arteries in patients with chronic limb-threatening ischemia. J Vasc Surg. 2025;82(5):1736-44.e1.\u003c/li\u003e\n\u003cli\u003eSiu HK, Schultz E, LeBrun S, Liou M, Kwan TW. Safety of Retrograde Tibial-Pedal Access and Intervention in Patients with Single Remaining Non-Occluded Infra-Popliteal Runoff Artery. J Cardiovasc Dev Dis. 2023;10(11).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"endovascular therapy, femoropopliteal artery, tibial artery, trans-ankle intervention","lastPublishedDoi":"10.21203/rs.3.rs-9339018/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9339018/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTrans-ankle intervention (TAI) through retrograde distal access via below-the-knee and below-the-ankle arteries has been increasingly reported as an alternative approach for the treatment of femoropopliteal (FP) lesions. Although previous studies have described the procedural success of this strategy, its clinical feasibility and postprocedural outcomes remain insufficiently characterized.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this retrospective single-center study, the data of 33 patients with 36 FP lesions who underwent endovascular therapy (EVT) between January 2024 and January 2025 were analyzed. The primary endpoint was procedural success. The secondary endpoints were clinical worsening of lower-limb ischemia within 30 days, 1-year freedom from clinically driven target lesion revascularization (CD-TLR), and procedural complications. The risk of post-procedure access vessel occlusion was also investigated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTAI via the anterior tibial artery (ATA) to the dorsalis pedis artery was performed in all patients. Procedural success was achieved in all cases, and the rate of 1-year freedom from CD-TLR was 91.8%. All patients had FP lesions, including three cases up to the iliac artery. 42% was chronic total occlusion, and EVT of the ATA was required in 42% of the cases to establish the access route. No patients showed clinical worsening within 30 days. The risk factors for ATA occlusion were hemodialysis, ATA intervention, and approach via the occluded ATA.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eTAI showed feasible results, especially for FP lesions without serious complications. Although no clinical worsening was observed, an increased risk of postoperative ATA occlusion existed in patients on hemodialysis and those with access site atherosclerosis requiring ATA intervention. However, this limitation may potentially be surmounted by approaching through the occluded ATA.\u003c/p\u003e","manuscriptTitle":"Clinical feasibility of endovascular therapy via trans-ankle intervention: a retrospective single-center study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-22 05:42:57","doi":"10.21203/rs.3.rs-9339018/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-04-13T18:15:22+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-13T14:34:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-10T12:10:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"CVIR Endovascular","date":"2026-04-09T21:05:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bc10a8c6-2dfa-48a9-bc3b-bf87a4eec6ce","owner":[],"postedDate":"April 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T05:42:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-22 05:42:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9339018","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9339018","identity":"rs-9339018","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}