Intentional subintimal loop technique for orientation recovery in superficial femoral artery chronic total occlusion with pedal-origin controlled antegrade and retrograde subintimal tracking.

Chronic total occlusion (CTO) of the superficial femoral artery (SFA) with flush occlusion and complete loss of the true lumen orientation remains a major technical challenge during endovascular interventions. Antegrade crossing may be hindered by ambiguous proximal caps and extensive collateral formation; however, intravascular imaging guidance is not always feasible. The case of a patient with a flush-occluded mid-SFA CTO in whom both antegrade and retrograde guidewire escalation failed to establish true lumen orientation is reported. External vascular ultrasound guidance and bidirectional wiring also fail to reliably identify the true position of the lumen in either direction. To overcome this limitation, an intentional subintimal loop technique using an 0.014-inch guidewire was used to restore spatial orientation and facilitate controlled advancement. Subsequently, a pedal-origin controlled antegrade and retrograde subintimal tracking technique was performed using a 4.0-mm balloon inflated at the popliteal artery, enabling successful guidewire connection and lesion traversal. The occluded SFA was treated with a drug-coated balloon to achieve satisfactory angiographic results. At the 6-month follow-up, computed tomography angiography demonstrated sustained patency of the treated SFA segment and preservation of the pedal access vessel. This case highlights the utility of an intentional subintimal loop technique to regain orientation in complex SFA CTOs when conventional strategies fail and suggests that pedal-origin controlled antegrade and retrograde subintimal tracking using a 4.0-mm balloon may represent a feasible bailout option without compromising distal vessel integrity.