A Modified Technique for Converting Retrograde Femoral Artery Access to Antegrade Access With the Assistance of a Long Sheath

BACKGROUND: Percutaneous femoral access serves as the cornerstone of endovascular therapy of lower extremity arterial disease. In complex cases, the arterial disease of lower extremity are involve in ipsilateral iliac artery pathology, which conventional treatment strategies typically require multiple punctures or staged procedures. AIMS: This study aimed to explore the bilateral lower extremity endovascular intervention of patients with coexisting ipsilateral iliac artery stenosis using the long sheath-assisted access conversion technique (LS-ACT) via a single puncture. METHODS: This is a retrospective cohort study of 18 patients with arteriosclerosis obliterans of the lower extremity who were treated between April 2023 and July 2025. The cohort included 13 males and 5 females, with a mean age of 70.4 ± 7.2 years. After retrograde femoral access, contralateral interventions were performed using the LS-ACT protocol. RESULTS: The LS-ACT was performed in all 18 patients, achieving successful transition from femoral retrograde to antegrade access. Seven of these patients underwent simultaneous bilateral lower extremity arterial interventions. In 11 patients, the LS-ACT was utilized following failed antegrade puncture due to obesity, scarred puncture sites, or a high bifurcation of the profunda femoris artery. Notably, 8 patients presented with hemodynamically significant improvement of ipsilateral iliac artery stenosis, including 2 who had undergone prior stenting. No LS-ACT relevant complications occurred. CONCLUSION: The LS-ACT demonstrates substantial clinical utility in real-world practice. It is particularly valuable for patients with ipsilateral iliac artery stenosis or those requiring single-session bilateral lower extremity interventions, and represents a reliable alternative in cases of failed antegrade puncture or when managing bilateral disease.