ObjectivePopliteal access (PA) as an alternative to conventional femoral access has not been reported in the office-based catheter laboratory setting (OBL) and may be perceived to have higher risks. The purpose of this study is to evaluate the safety and efficacy of popliteal access for endovascular treatment of iliofemoral arterial occlusive disease in an OBL setting. MethodsFrom 10/2018 - 10/2023 a total of 1,408 PAD interventions were performed in our OBL. A cohort of 27 popliteal access consecutive procedures for femoral and iliac artery occlusions were studied. All interventions were done using a micro-puncture needle under ultrasound guidance. All patients were discharged 1 hour after completion of the procedure. Indications for popliteal access were presence of aortoiliac stent/grafts, aorto-bifemoral or aortoiliac bypasses, difficult contralateral or antegrade femoral access, and flush superficial femoral artery (SFA) occlusions. Procedures were determined to be successful upon complete resolution of the target lesions and safety was measured peri-operatively and at 90-days. Patency was determined clinically, by arterial duplex, and by need for reintervention up to 2 years. Results27 popliteal access procedures were performed in 25 patients (21 complete femoral artery occlusions, 6 severe stenosis). Iliac disease was present in 9. Indications for PA were existing aortoiliac stent graft 11, aorto-bifem-iliac bypass 4, non-crossable iliac occlusions 3, failed antegrade femoral access 4, flush SFA occlusion 3, and bilateral common femoral artery disease precluding access 2. TASC pre-op was B: 4, C: 4, D:19. Treatments included atherectomy/balloon angioplasty (BA) and stent 12, BA and stenting 4, atherectomy/BA 5, BA alone 6. Successful opening of occlusions occurred in 25/27 (92.5%). No complications or major adverse cardiac events (MACE) occurred except 1 asymptomatic small popliteal AV fistula. Of the 25 successful procedures duplex patency at 3, 6 & 12 months was 19/20 (95%), 11/15 (69.3%) & 11/13 (61%). Rutherford Classification improved from pre-op > 4 in 24/27 (89%) to post-op < 2 at 1 month in 23/23 (100%), 3 months in 19/20 (95%), 6 months in 11/15 (69.3%), 12 months in 11/13 (61%). Freedom from re-intervention at 3 months in 19/20 (95%), 6 months in 13/15 (86%), and 12 months in 12/13 (79%). ConclusionsPopliteal artery access for complex iliofemoral disease is safe and effective and should be considered as a valid alternative option in the OBL setting.