Objectives: To compare the safety and efficacy of retrograde trans-popliteal access in total Superficial Femoral Artery (SFA) occlusions (TASK II-D) in surgical high-risk patients, in the presence of a patent popliteal artery, after unsuccessful antegrade lesion crossing attempts.   Patients and methods: This is a retrospective study including 58 surgical high-risk patients with TASC II D femoro-popliteal occlusive diseases. After failure of antegrade access to cross the occlusion in 9 patients, medial retrograde trans-popliteal access was successfully achieved, followed by snaring of the retrograde wire through rendezvous technique. Perioperative complications and technical success were compared between different access groups.   Results: 58 patients were included in the study; 15 men (25.9%) and 43 women (74.1%). 42 patients (72.4%) underwent contralateral retrograde access at Common Femoral Artery (CFA), 7 patients (12.1 %) ipsilateral antegrade access at CFA, 9 patients (15.5%) ipsilateral retrograde access at popliteal artery. All patients were ASA grade 4. Technical success was highest with contralateral retrograde entailing 40 cases (95.2%), followed by ipsilateral ante-grade access (6 cases - 85.7%) and lowest with ipsilateral retrograde (7 cases-77.8%).   Conclusion: Transpopliteal retrograde approach can be utilized safely and efficiently using a medial infracondylar retrograde popliteal puncture, with the patient in the supine position. Furthermore, this retrograde popliteal approach can be considered a valid alternative for SFA or proximal PA recanalization after a failed antegrade approach, especially in high risk surgical patients (ASA 4).