Introduction:
Chronic total occlusion (CTO) of the common iliac artery (CIA) represents a technically challenging subset of aorto-iliac occlusive disease, particularly when the lesion extends close to the aorto-iliac bifurcation. Although endovascular therapy has become the preferred treatment modality, the optimal access strategy for unilateral CIA CTO remains uncertain. This study aimed to evaluate the feasibility, procedural control, and clinical outcomes of a planned first-line bilateral femoral access strategy in unilateral CIA CTO.

Material and methods:
This retrospective single-centre study included 30 consecutive patients with unilateral CIA CTO who underwent endovascular revascularisation using a first-line bilateral femoral approach between January 2020 and December 2024. Continuous contralateral diagnostic angiography was used to guide the lesion crossing and stent deployment. Lesions were classified according to the TransAtlantic Inter-Society Consensus (TASC II). Technical success was defined as residual stenosis < 30% with restoration of antegrade flow. Procedural complications and mid-term clinical outcomes were assessed.

Results:
Most lesions were classified as TASC II C–D (86.7%). Technical success was achieved in 93.3% of cases. Periprocedural complications were infrequent and included access-site haematoma (6.7%), flow-limiting dissection (3.3%), and distal embolisation (3.3%). During a median follow-up of 13 months, symptom recurrence occurred in 20.0% of patients. Imaging performed in symptomatic patients confirmed restenosis or reocclusion in 13.3%, and target lesion revascularisation was required in 10.0% of cases.

Conclusions:
A planned first-line bilateral femoral endovascular approach for unilateral CIA CTO is feasible and safe, achieving high technical success with low complication rates even in predominantly TASC II C–D lesions. By enhancing procedural control and bifurcation preservation, this strategy may be particularly valuable in anatomically complex cases.