Successful endovascular treatment for retroflexed anterior tibial artery origin in chronic limb-threatening ischemia.

The success rate of endovascular treatment (EVT) for infrapopliteal lesions has increased significantly; however, EVT can be particularly challenging when the anterior tibial artery (ATA) originates in a retroflexed configuration. An 86-year-old man presented with rest pain in the right lower extremity (Rutherford category 4). Angiography revealed severe proximal ATA stenosis. Multiple attempts at antegrade wiring failed because of difficulty in engaging the ATA origin. Therefore, a retrograde approach via the dorsalis pedis artery was established. Retrograde angiography demonstrated that the ATA originated from a retroflexed branch of the popliteal artery (POPA). Initially, the retrograde guidewire advanced in a subintimal course toward the POPA, but eventually, the guidewire successfully passed along the course of the blood vessel. However, proximal reversal of direction was difficult using guidewire manipulation alone. Therefore, a snare catheter was introduced via the antegrade system, and the retrograde guidewire was successfully captured and externalized. Subsequently, balloon angioplasty was performed, which resulted in satisfactory revascularization and restoration of antegrade blood flow. A retroflexed ATA represents a unique anatomical challenge that can lead to difficulties in guidewire advancement. In such cases, clear visualization of the vessel route and snare-assisted guidewire externalization is critical determinants of successful revascularization. We must continue to improve the success rate of EVT for infrapopliteal lesions by steadily developing treatment strategies, while carefully examining the advantages and disadvantages of various EVT procedures.