Extreme retrograde metatarsal puncture in a complex CLI case

After an unsuccessful antegrade recanalization attempt of the ATA/DP  due to vessel perforation, an extreme retrograde puncture of the first metatarsal artery was performed. Following a  1.5 mm balloon dilatation, the rendezvous of the wires was obtained using the CART technique. 2 mm DCB balloon angioplasty of the DP, 2.5mm for the distal ATA and 3mm for the proximal ATA were subsequently performed.  The completion angio showed full blushing of the target lesion, and  excellent flow on the forefoot including the plantar arch.