subintimal angioplasty ( sa ) has been found to be an effective method for the treatment of long superficial femoral artery ( sfa ) occlusions.1 ) in this technique , a wire is advanced across the occlusion in the subintimal space , and then it re - enters the true vessel lumen distal to the occlusion . one of the major factors that limit the success of this procedure is the failure of the wire to re - enter the true lumen.2 ) this issue is often related to the presence of severe calcification in the vessel wall . in this report , we present a case where an initially unsuccessful antegrade sa due to failure to re - enter the distal true lumen was rescued by using a retrograde subintimal approach through the distal sfa . an 81-year - old male patient visited our hospital for right leg pain at rest ( fontaine class iii ) . his comorbidities included hypertension , current smoking , and a previous non - st elevation myocardial infarction in september 2010 which was treated with percutaneous coronary intervention and stent implantation in the right coronary artery . in addition , he also had chronic kidney disease because of long - standing hypertension and apical hypertrophic cardiomyopathy discovered on echocardiography . his left ventricular function was preserved ( ejection fraction=64% ) , but there was a regional wall motion abnormality in the right coronary artery . angiogram performed via the left common femoral access showed an occlusion of about 25 cm of the right superficial femoral artery ( sfa ) with reconstitution of the distal sfa and popliteal artery ( fig . 1a and b ) . a 7 fr balkin sheath ( cook inc . , bloomington , in , usa ) was inserted into the right external iliac artery , and an angled 0.035-inch hydrophilic guidewire ( radifocus ; terumo , tokyo , japan ) through a 5 fr catheter ( glidecath ; terumo , tokyo , japan ) was used to create a subintimal dissection plane above the level of the occlusion . after successful formation of the subintimal dissection and wire loop , the wire was advanced through the subintimal space down to the distal occlusion site with the support of a glide catheter . however , re - entry of the wire into the true lumen distal to the occlusion was not possible ( fig . , redwood city , ca , usa ) was used in an attempt to enter the true lumen , but this attempt failed ( fig . since the distal sfa was disease - free and normal in caliber , a retrograde approach through the distal sfa was planned as an alternative . for performing a retrograde approach through the distal sfa , a roadmap of the vessels was first obtained by injecting the contrast in an antegrade direction . the distal sfa was then punctured at the proximal part of the adductor canal with a 21-gauge micropuncture needle ( cook inc . , a 0.018-inch guide wire was advanced to the distal sfa following successful puncture , and an angiogram was performed through a 3 fr dilator to confirm that the access to the sfa was achieved properly . an angled 0.035-inch hydrophilic wire with the support of the 5 fr glide catheter was advanced through the subintimal space in a retrograde fashion . the retrograde wire was successfully passed into the true lumen of the left common femoral artery , and then dilation with a 5.0150 mm balloon was performed . the hydrophilic guide wire was successfully passed through the dissected channel in an antegrade fashion , and two self - expanding nitinol stents ( smart 6150 mm , smart 7120 mm ; cordis , miami , fl , usa ) were placed in the sfa , which yielded a satisfactory final result ( fig . 3 ) . following the procedure , complete hemostasis after insertion of the sheath into the distal sfa was achieved without the use of hemostatic devices other than elastic bandages and manual compression , and access site complications did not occur . since the time bolia first introduced subintimal angioplasty,3 ) this technique has been an indispensable recanalization technique for chronic total occlusions in the sfa and has provided a high procedural success rate with acceptable long - term outcomes when combined with stenting.1 ) this technique involves intentional advancement of a wire across the occlusion in the subintimal space to ultimately exit into the true vessel lumen distal to the occlusion . however , its utility is limited by the inability to re - enter the true lumen from the subintimal space , which occurs in 13 to 26% of the cases . distal re - entry devices , such as the intravascular ultrasound ( ivus)-guided crosspoint transaccess catheter ( trans - vascular , menlo park , ca , usa ) or the outback catheter ( perclose , ca , usa ) , were developed to overcome re - entry failure and they are being widely used.4)5 ) however , utilizing these re - entry devices does not entirely preclude the possibility of failure to find the true lumen . in our case , we unsuccessfully attempted to re - enter the distal true lumen several times using a re - entry device . since tnnesen et al.6 ) first reported the utility of retrograde popliteal access in 1988 , this approach has proved to be a useful alternative method for challenging sfa interventions.7)8)9 ) however , the need for repositioning the patient during the procedure and the potential risk of complications , such as popliteal artery occlusion and arteriovenous fistula due to unintentional puncture of the popliteal vein , have impeded wider acceptance of the retrograde approach.8 ) furthermore , once the patient 's position is changed to a prone position , the remaining procedures need to be performed via the popliteal access only . however , in our case , the distal sfa access allowed the patient to remain in the supine position throughout the procedure , thus enabling direct visualization of both arterial access points and maintenance of necessary sterile conditions at both sites . several authors have reported puncture site complication rates associated with the popliteal artery access between 2.5% and 5.2%.9)10 ) the primary reason for the development of complications including arteriovenous fistula or gross hematoma is the proximity between the artery and the vein in the popliteal fossa.11 ) in addition , popliteal lesions are not a routine indication for stent therapy because popliteal stenting is assumed to be associated with a high risk of re - stenosis and fracture.12 ) there are several advantages of a distal sfa access . traditional retrograde popliteal access requires turning the patient from a supine to a prone position . this maneuver increases the patient anxiety and creates an uncomfortable situation , especially for patients who are obese or have impaired respiratory function . some research groups developed a popliteal artery puncture technique performed by flexing and medially rotating the knee , which also causes discomfort to the patient . second , the femoral vein is located lateral to the sfa in the proximal portion of the adductor canal , and therefore , distal sfa access is associated with a lower risk of puncturing the vein than popliteal access , and thus , the risk of arteriovenous fistula is reduced . third , unlike the popliteal artery , a stent can be inserted into the sfa as long as the lesion does not involve the adductor canal . one of the disadvantages of a popliteal access is that if the puncture results in vascular occlusion or dissection and worsens limb ischemia , the stent can not be inserted , and only techniques such as long - duration ballooning can be used as alternatives . on the contrary , in case of distal sfa access , the stent may be inserted as far as the adductor canal even when the access site is dissected or occluded . furthermore , although the procedure can only be performed in the retrograde direction once the patient is turned into the prone position , it can be performed in both ante- and retrograde directions if the patient is maintained in the supine position . the artery is located deep in the muscle , and therefore its pulsation can not be readily felt . however , a roadmap fluoroscopic guidance assists in gaining access to the sfa . second , the sfa can not be directly compressed to achieve hemostasis , because the distal sfa is surrounded by muscles ; and in our case , there were no leakages after the removal of the sfa sheath . this case demonstrates that a distal sfa approach in the supine position can serve as a convenient option for treating sfa occlusion in the setting of failed antegrade angioplasty .
subintimal angioplasty is an effective method for the treatment of long superficial femoral artery ( sfa ) occlusions . 
 one of the major limiting factors for the success of this procedure is the failure to re - enter the true lumen . 
 the recently introduced luminal re - entry devices provide a high technical success rate , but failures can occur . in such cases , a retrograde popliteal approach can serve as a potential backup option . however , the need to reposition the patient remains a drawback . here 
 , we report a case of an 81-year - old male with a long sfa occlusion treated using a retrograde distal sfa approach in the supine position after the initial failure of antegrade angioplasty .