Retrograde Collateral Crossing Through Riolan's Arcade With Femoral Antegrade Reconstruction After Traction During Upper-Extremity Externalization.

BACKGROUND: Flush superior mesenteric artery (SMA) occlusion without a discernible stump remains one of the most challenging scenarios in the endovascular treatment of chronic mesenteric ischemia. CASE SUMMARY: A 59-year-old woman presented with chronic mesenteric ischemia. Computed tomographic angiography demonstrated flush SMA occlusion with collateral perfusion through Riolan's arcade. Antegrade crossing failed because the SMA ostium could not be selectively engaged. Retrograde collateral crossing through Riolan's arcade was successfully achieved. Although upper-extremity externalization was technically successful, progressive abdominal pain developed during sustained traction, raising concern for excessive mesenteric tension and potential collateral vessel injury. The reconstruction strategy was therefore converted to a femoral antegrade approach. Successful SMA revascularization was achieved. Symptoms resolved, and follow-up computed tomographic angiography confirmed sustained SMA patency. DISCUSSION: This case highlights a strategy of retrograde collateral crossing followed by femoral antegrade reconstruction for flush SMA occlusion. Conversion to femoral reconstruction may reduce collateral traction while facilitating definitive endovascular treatment. TAKE-HOME MESSAGE: In complex SMA chronic total occlusion, retrograde collateral crossing through Riolan's arcade can facilitate lesion traversal, whereas femoral antegrade reconstruction may offer a lower-traction and more controlled pathway for definitive mesenteric revascularization.