Background Trans-ankle intervention (TAI) through retrograde distal access via below-the-knee and below-the-ankle arteries has been increasingly reported as an alternative approach for the treatment of femoropopliteal (FP) lesions. Although previous studies have described the procedural success of this strategy, its clinical feasibility and postprocedural outcomes remain insufficiently characterized.Methods In this retrospective single-center study, the data of 33 patients with 36 FP lesions who underwent endovascular therapy (EVT) between January 2024 and January 2025 were analyzed. The primary endpoint was procedural success. The secondary endpoints were clinical worsening of lower-limb ischemia within 30 days, 1-year freedom from clinically driven target lesion revascularization (CD-TLR), and procedural complications. The risk of post-procedure access vessel occlusion was also investigated.Results TAI via the anterior tibial artery (ATA) to the dorsalis pedis artery was performed in all patients. Procedural success was achieved in all cases, and the rate of 1-year freedom from CD-TLR was 91.8%. All patients had FP lesions, including three cases up to the iliac artery. 42% was chronic total occlusion, and EVT of the ATA was required in 42% of the cases to establish the access route. No patients showed clinical worsening within 30 days. The risk factors for ATA occlusion were hemodialysis, ATA intervention, and approach via the occluded ATA.Conclusions TAI showed feasible results, especially for FP lesions without serious complications. Although no clinical worsening was observed, an increased risk of postoperative ATA occlusion existed in patients on hemodialysis and those with access site atherosclerosis requiring ATA intervention. However, this limitation may potentially be surmounted by approaching through the occluded ATA.