Pedal Pull-Through Rail and Wingman-Assisted Coaxial Push for Entrapped Device Retrieval in Calcified Tibial Arteries

To describe a bailout technique for retrieving an entrapped, fractured endovascular device fragment in severely calcified below-the-knee arteries when conventional snare retrieval is not feasible.

1) Immediately stop manipulation and maintain the position of the antegrade guidewire holding the fragment (the "Golden Rule"); 2) obtain retrograde access; 3) advance a snare from the retrograde sheath to capture and externalize the existing antegrade guidewire, creating a pull-through rail without wire exchange; 4) advance a Wingman catheter antegradely over the rail; and 5) apply short, coaxial pushes to dislodge the fragment and retrieve it via the retrograde sheath.

Retrograde distal puncture and sheath insertion are difficult without a sufficient vascular diameter in either the dorsal foot artery or posterior tibial artery. Avoid loss of the guidewire during procedure and vessel injury.

Never surrender the workhorse wire holding the fragment; converting it into a pull-through rail enables safe coaxial dislodgement.