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Introduction Critical limb ischemia (CLI) management has been dominated by endovascular advances in the last decade. The latest paradigm change in preventing amputation in CLI patients is utilization of pedal artery access.2,3 Pedal artery access requires that the peripheral interventionalist master the following components of tibiopedal access: Retrograde pedal artery access of the tibioperoneal vessels and combination access with the antegrade femoral artery; The use of duplex ultrasound for securing access of infrapopliteal arteries; Skills to reenter the true lumen from an intimal dissection plane; Use of equipment such as snares to capture wires and establish a rail to enable delivery of balloons and stents. The advent of retrograde tibiopedal approach to revascularize complex lesions in patients with CLI has proven to be feasible, safe, and favorably modifies the failure rate associated with the antegrade-only approach. We recently performed three cases of SFA revascularization using a retrograde tibiopedal approach at Health Central Hospital with excellent outcomes. Herein, we present one of three cases and discuss the technique, safety, efficacy, and benefit of this emerging treatment approach. Advantages of tibiopedal access • Small diameter of tibial vessels may help to increase the successful crossing of catheter or wire through occlusion. • Less likelihood of entering side branch or collateral. • The most difficult portion of the occlusion is the proximal cap; the distal cap is often softer and less difficult. • In cases of occluded short segment tibial or popliteal arteries, the pedal approach may offer a shorter arterial segment to cross with balloons, catheters, and stents than traditional ipsilateral or contralateral approaches. • Useful in cases in which vessel size precludes use of embolic protection devices during antegrade or retrograde femoral approaches. • May have safety potential in obese patients in whom a groin approach may not be feasible or who cannot be turned to a prone position for popliteal access. • May have a role in patients having a hostile or infected groin in which conventional intervention is not feasible. • Shortened procedure time, since patient need not be flipped over. The size of tibial vessels poses the biggest challenge for the peripheral Interventionalist and access via duplex ultrasound guidance is recommended to achieve successful access because multiple attempts may contribute to significant bleeding, nerve compression or even compartment syndrome. Using this method, the probe should be placed in the first metatarsal space. Presence of a Doppler signal can prove useful to obtain access with a front wall puncture with a micropuncture needle. Potential disadvantages of tibiopedal access • Small-diameter vessels are prone to spasm and dissection. • Vessels are often calcified. • Approach near the ankle may cause significant difficulty in sheath passage, because of the sharp angulations. • Long procedure time and excess contrast use. • If a pedal artery is the last remaining infrapopliteal vessel, it should not be damaged, in order to avoid jeopardizing future femoral-to-infrapopliteal bypass chances. Summary Pedal access is a relatively recent innovation for peripheral vascular interventions. It is a feasible approach with potential immediate benefits that may increase its utilization. However, there is a learning curve involved with this interventional approach, and we will continue to gain further understanding of its ideal uses in the time to come. The retrograde tibiopedal approach is superior to the popliteal approach, since it does not involve turning the patient from supine to prone position. Our results show that percutaneous transluminal angioplasty (PTA) is feasible as a primary invasive treatment for distal SFA and infra-popliteal atherosclerotic occlusive lesions in patients with chronic CLI. This technique enables us to achieve more successful revascularization and limb salvage with lower complication rates.