A novel troubleshooting technique for below-the-knee artery occlusions with proximal cap ambiguity: Transpedal Retrograde Wire Just Marker Technique.

BackgroundChronic total occlusions with ambiguous proximal caps pose a challenging problem in below-the-knee artery endovascular interventions.Case ReportWe defined a new technique for antegrade puncture and penetration of an ambiguous proximal cap in a 52-year old male patient with a non-healing wound on his right forefoot. Anterior tibial artery (ATA) was determined as the target vessel; however, its origin and course could not be determined. A retrograde guidewire (Asahi Gladius 0.018 inch, Asahi Intecc) was advanced into the distal ATA via transpedal loop following pedal loop angioplasty. This guidewire was advanced through and parked to the tibioperoneal trunk with a small distal loop at the tip. While the looped wire was held in its position as a marker for ATA ostium, a second guidewire (Asahi Gladius 0.018 inch, Asahi Intecc) with the guidance of 4F vertebral catheter (Vert Catheter, Merit Medical) successfully penetrated the ambiguous cap and subsequent target vessel revascularization was achieved with 2.5/150 mm peripheral balloon angioplasty catheter (Minerva SC 0.018 inch, BrosMed Medical).ConclusionTranspedal Retrograde Wire Just Marker Technique is a novel and practical technique which can be used in chronic total occlusions of below-the-knee arteries with ambiguous proximal caps.