Retrograde Peroneal Artery Access for Arterial Flossing: A Single-Center Experience

Sunday, March 30, 2025

3:36 PM – 3:45 PM CT

Location: Music City Center, 205 BC

Presenting Author(s)

Subhash Gutti, MD (he/him/his)

PGY-2
RUSH VIR, United States

Author/Co-author(s)

Aesha Patel, MD

Resident Phyisican
Rush University Medical Center, United States
SM

Sreekumar Madassery, MD, FSIR

Physician
Rush University Medical Center, United States
UT

Ulku Turba, MD, FSIR

Professor
Rush University Medical Center, United States
Bulent Arslan, MD, FSIR

Professor and Interim Chair
Rush University Medical Center, United States

Purpose: Arterial flossing, which can be performed in the true lumen or subintimal plane, is an advanced recanalization technique utilized in challenging CTO cases when traditional endovascular approaches are unsuccessful. In the vast majority of reported peripheral arterial flossing cases, the DP, AT, or PT arteries are utilized as the retrograde access targets {1}. Peroneal artery access has historically been avoided due its deep course which poses risks to hemostasis, and its small diameter which makes it a difficult access target {2}. Despite these challenges, some CLTI patients have only single-vessel runoff via the peroneal artery, making this the only viable revascularization option.

Materials and Methods: In this retrospective study, we report our single-institution experience utilizing retrograde peroneal artery access for peripheral arterial flossing in CLTI patients with no other tibio-pedal access options.

Results:
Between July 2012 and September 2024, our institution utilized retrograde peroneal access with arterial flossing for 20 cases (17 SAFARI, 3 true-lumen flossing). Technically successful revascularization was achieved in 95% of cases. Hemostasis was achieved at all access sites in 100% of cases. Balloon angioplasty was utilized to achieve peroneal artery hemostasis in 80% of cases. In addition to balloon tamponade of the access site, some cases utilized additional hemostatic techniques including Gelfoam of the needle tract. There was only 1 case involving an immediate complication (distal thrombus which resolved following catheter-directed thrombolysis).
For the 18 patients who reached the 6-month follow-up period, primary patency was 50%, amputation-free survival rate was 78%, and mortality rate was 0%. These results are particularly noteworthy, given this cohort was considered to have no alternative revascularization options at the time of intervention.

Conclusion: For CLTI patients lacking alternative tibio-pedal access targets, retrograde peroneal access with flossing technique can be a safe and effective limb-salvage option with durable outcomes. Operators can mitigate risks of retrograde peroneal access by optimizing access technique and utilizing balloon angioplasty for hemostasis. Further long-term data on peroneal access is necessary for a more comprehensive outcomes analysis.