Tips and Tricks for Simple and Complex Below-the-Ankle Punctures

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