Excimer Laser Atherectomy Research Articles

Prevalence, indications and management of balloon uncrossable chronic total occlusions: Insights from a contemporary multicenter US registry.

Balloon uncrossable lesions can be challenging to treat, requiring specialized techniques and equipment. We examined the prevalence, clinical and angiographic characteristics, management and procedural outcomes of balloon uncrossable lesions in a multicenter chronic total occlusion (CTO) percutaneous coronary intervention (PCI) registry. Between 2012 and 2016, 718 CTO PCIs (in which the occlusion was successfully crossed with a guidewire) were performed in 701 patients at 11 US centers. Mean age was 65.6 ± 10 years and 84% of the patients were men. Balloon uncrossable lesions represented 9% of all CTOs. Balloon uncrossable CTOs had more moderate/severe calcification (82% vs. 52%, P < 0.0001), moderate/severe tortuosity (61% vs. 35% P < 0.0001) and higher J-CTO score (2.95 ± 1.32 vs. 2.43 ± 1.23, P = 0.005) as compared with the remaining lesions. Technical and procedural success was significantly lower for balloon uncrossable lesions (90.5% vs. 98.3%, P < 0.0001 and 88.9% vs. 96.6% P = 0.004), respectively, but the incidence of major adverse events was similar (1.6% vs. 2.2%, P = 0.751). Balloon uncrossable lesions required longer procedure (208 [interquartile range: 135, 258] vs. 135 [94, 194] min, P < 0.0001) and fluoroscopy (77 [52, 100] vs. 45 min [27, 75], P < 0.0001) time. Techniques used to treat balloon uncrossable lesions included balloon-assisted microdissection (23%), excimer laser atherectomy (18%), and rotational atherectomy (16%). Excimer laser atherectomy and balloon-assisted microdissection were associated with the highest technical and procedural success rates. Balloon uncrossable CTOs are common, are associated with high rates of technical failure, and require specialized techniques for successful treatment. © 2016 Wiley Periodicals, Inc.

Peripheral artery disease: Laser light show--targeting in-stent restenosis in peripheral arteries with excimer laser atherectomy.

Peripheral artery disease: Laser light show—targeting in-stent restenosis in peripheral arteries with excimer laser atherectomy

Randomized controlled study of excimer laser atherectomy for treatment of femoropopliteal in-stent restenosis: initial results from the EXCITE ISR trial (EXCImer Laser Randomized Controlled Study for Treatment of FemoropopliTEal In-Stent Restenosis).

The purpose of this study was to evaluate the safety and efficacy of excimer laser atherectomy (ELA) with adjunctive percutaneous transluminal angioplasty (PTA) versus PTA alone for treating patients with chronic peripheral artery disease with femoropopliteal bare nitinol in-stent restenosis (ISR). Femoropopliteal stenting has shown superiority to PTA for lifestyle-limiting claudication and critical limb ischemia, although treating post-stenting artery reobstruction, or ISR, remains challenging. The multicenter, prospective, randomized, controlled EXCITE ISR (EXCImer Laser Randomized Controlled Study for Treatment of FemoropopliTEal In-Stent Restenosis) trial was conducted across 40 U.S. centers. Patients with Rutherford Class 1 to 4 and lesions of target lesion length ≥4 cm, vessel diameter 5 to 7 mm were enrolled and randomly divided into ELA + PTA and PTA groups by a 2:1 ratio. The primary efficacy endpoint was target lesion revascularization (TLR) at 6-month follow up. The primary safety endpoint was major adverse event (death, amputation, or TLR) at 30 days post-procedure. Study enrollment was stopped at 250 patients due to early efficacy demonstrated at a prospectively-specified interim analysis. A total of 169 ELA + PTA subjects (62.7% male; mean age 68.5 ± 9.8 years) and 81 PTA patients (61.7% male; mean age 67.8 ± 10.3 years) were enrolled. Mean lesion length was 19.6 ± 12.0 cm versus 19.3 ± 11.9 cm, and 30.5% versus 36.8% of patients exhibited total occlusion. ELA + PTA subjects demonstrated superior procedural success (93.5% vs. 82.7%; p = 0.01) with significantly fewer procedural complications. ELA + PTA and PTA subject 6-month freedom from TLR was 73.5% versus 51.8% (p < 0.005), and 30-day major adverse event rates were 5.8% versus 20.5% (p < 0.001), respectively. ELA + PTA was associated with a 52% reduction in TLR (hazard ratio: 0.48; 95% confidence interval: 0.31 to 0.74). The EXCITE ISR trial is the first large, prospective, randomized study to demonstrate superiority of ELA + PTA versus PTA alone for treating femoropopliteal ISR. (Randomized Study of Laser and Balloon Angioplasty Versus Balloon Angioplasty to Treat Peripheral In-stent Restenosis [EXCITE ISR]; NCT01330628).

ELA Useful in Treatment of Femoropopliteal ISR

Use of excimer laser atherectomy (ELA) as an adjunct to percutaneous transluminal angioplasty (PTA, also known as balloon angioplasty) is superior to PTA alone in patients with peripheral artery disease who experience artery narrowing following stent implantation (in-stent restinosis [ISR]). This article discusses the results from the Randomized Study of Laser and Balloon Angioplasty Versus Balloon Angioplasty to Treat Peripheral In-Stent Restenosis [EXCITE ISR; NCT01330628].

TCT-531 EXCITE ISR: A Prospective, Randomized Controlled Trial of Excimer Laser Atherectomy vs Balloon Angioplasty for the Treatment of Femoropopliteal In-Stent Restenosis

Femoropopliteal stenting for treatment of peripheral arterial disease has shown superiority to balloon angioplasty (PTA) for the treatment of lifestyle limiting claudication and critical limb ischemia. However, in-stent restenosis (ISR) after femoropopliteal artery stenting remains a challenging

Photoablation Using theTurbo-Booster andExcimer Laser for In-Stent RestenosisTreatment: Twelve-Month Results From the PATENT Study

To evaluate the performance of the Turbo Elite laser catheter in combination with the Turbo-Booster guiding catheter for the treatment of femoropopliteal in-stent restenosis (ISR). The PATENT study (Photoablation Using the Turbo-Booster and Excimer Laser for In-Stent Restenosis Treatment) was a multicenter prospective industry-sponsored registry involving 5 European centers. Patients with symptomatic femoropopliteal ISR (Rutherford categories 2-5) and an ankle-brachial index ≤0.8 were treated with excimer laser atherectomy (ELA). Ninety patients (65 men; mean age 69.5±9.3 years) were enrolled. The majority of patients were Rutherford category 3 (63, 71.6%), and 32 (35.6%) patients had previous treatment for ISR. The average lesion length was 123±95.9 mm, and 30 (34.1%) lesions were total occlusions. The main efficacy outcome was primary patency at 12 months as measured by duplex ultrasonography. The primary safety outcome was freedom from major adverse events (MAE) during hospitalization and at 30-day follow-up to include all death, unplanned major amputation, or target lesion revascularization (TLR). The Turbo Elite laser catheter created a pilot channel in 87 (96.7%) of 90 lesions, with a mean of 1.5 passes, followed by the Turbo Booster with a mean of 5.7 passes. Adjunctive balloon dilation was performed in 79 (87.8%) lesions. Procedure success (<30% residual stenosis without stenting) was 96.7%. The mean percentage stenosis improved from a baseline of 87.0% to 32.3% after laser atherectomy and to 7.4% after final treatment. The MAE rate through 30 days was 2.2%. Nine (10.0%) patients experienced distal embolization. Estimates of freedom from TLR at 6 and 12 months were 87.8% and 64.4%, respectively. Primary patency at 6 and 12 months was 64.1% and 37.8%, respectively. Only a history of prior intervention for ISR (p<0.01) was a predictor of TLR at 12 months. The PATENT study has established excimer laser atherectomy as safe for the treatment of femoropopliteal ISR, achieving high procedure success. Recurrence of restenosis indicates that removing hyperproliferative tissue alone does not solve the problem of ISR. New concepts, such as the combination of ELA with drug-eluting balloons, may prove beneficial.

Transpopliteal balloon-assisted excimer-laser atherectomy for the treatment of chronic femoropopliteal occlusions: feasibility and initial results.

PURPOSERecanalization of chronic total occlusions (CTOs) of the femoropopliteal arteries depends on a successful lesion crossing with the guide wire. The aim of this retrospective study was to evaluate the safety, feasibility, and the primary results of retrograde recanalization of CTOs with balloon-assisted excimer–laser atherectomy (ELA) via a transpopliteal approach after failed antegrade attempts.METHODSA total number of 15 patients (10 male, 5 female) with a mean age of 68.5 years (range: 43–91 years) treated with retrograde transpopliteal ELA in the years 2009–2012 were included retrospectively. After unsuccessful antegrade recanalization attempts with conventional guide wires and catheters, patients were treated with a retrograde recanalization attempt via a transpopliteal access using an excimer laser, followed by pressure-only balloon angioplasty (POBA). The mean length of the CTOs in the femoropopliteal arteries was 17.8 ± 5.4 cm (range: 9–29 cm).RESULTSTechnically successful recanalization was achieved in 14 of 15 patients. Provisional stenting was done in two cases. There were no major adverse events regarding the laser atherectomy or popliteal access site. One acute reocclusion was observed in the first 48 hours after intervention. The ankle-brachial Index increased from preinterventional 0.45 ± 0.07 to 0.77 ± 0.29 (P < 0.05) in the follow-up period (1.5 months), resulting in a primary patency of 80%.CONCLUSIONThe retrograde ELA for recanalization of chronic femoropopliteal occlusions via a popliteal access turned out to be a safe and effective procedure with promising primary results. Thus it may be an endovascular treatment option for long chronic occlusions after failed antegrade recanalization or in patients who are not suitable for surgery.

TCT-539 Differences in Patients' Selection and Outcomes of SilverHawk Atherectomy versus Laser Atherectomy in Treating In-Stent Restenosis of the Femoropopliteal Arteries: A Retrospective Analysis from a Single Center

Background: Treatment of in-stent restenosis (ISR) of the femoropopliteal (FP) artery remains a challenge to the endovascular specialist. Silverhawk (SA) and excimer laser atherectomy (ELA) use different mechanisms in restenotic tissue reduction. We report data on FP ISR treatment with SA and ELA in an unselected cohort of patients treated at a single center. Methods: Demographic, clinical, angiographic and procedural data was collected on all patients that underwent SA and ELA (laser Elite 83.3%, Booster or Tandem 16.7%) for FP ISR from January 2005 until June 2010. Major adverse events and oneyear target lesion revascularization (TLR) were obtained by review of medical records and phone calls. Univariate analysis was used to compare the 2 groups. Cox Regression analysis for TLR over time was performed to adjust for differences between the 2 cohorts and modeled for the following variables: SA vs. ELA, lesion length, TASC D lesions (versus A-C), diabetes, age, gender and bail out stenting. Results: 81 consecutive patients (41 SA, 40 ELA) were included in the analysis. ELA was utilized more frequently in longer lesions, subacute presentation, TASC D lesions, and in patients with more angiographic thrombus. Percent stenosis post ELA was 56.6% 0.7% vs SA 33.8% 7.5% (p1⁄40.015). Percent stenosis post ELA was 56.6% 0.7% vs SA 33.8% 7.5% (p1⁄40.015). Final angiographic success (< 30% residual narrowing post final treatment) was similar between ELA and SA respectively (92.5% vs. 100%, p1⁄40.12). Embolic filter protection was used equally in both modalities (ELA 57.5% vs. SA 56.1%, p1⁄41.00). DE requiring treatment occurred in 2.5% in ELA vs 7.3% of SA (p1⁄40.2). There were no device related complications. The primary outcome of TLR at 1 year occurred in 48.7% and 31.7% of ELA and SA respectively (p1⁄40.171). ELA had a steeper failure rate than SA in the first 6 months post treatment and to a lesser extent after 6 months, whereas SA showed lesser TLR initially but a higher TLR after 6 months. Cox Regression analysis showed that SA was a predictor of TLR at 1 year. Conclusions: Both SA and ELA continued to have high TLR rates in treating ISR of the FP arteries. SA appears to be a predictor of TLR at 1 year.

CRT-90 Safety and One-Year Revascularization Outcome of Excimer Laser Ablation Therapy in Treating In-Stent Restenosis of Femoropopliteal Arteries: A Retrospective Review from a Single Center

Treatment of in-stent restenosis of the femoropopliteal artery is challenging with a high rate of restenosis. Excimer laser atherectomy (ELA) has a theoretical advantage of ablating restenotic tissue and reducing or delaying the need for repeat revascularization. We present a retrospective analysis

Safety and One-Year revascularization outcome of excimer laser ablation therapy in treating in-stent restenosis of femoropopliteal arteries: A retrospective review from a single center

Treatment of in-stent restenosis of the femoropopliteal (FP) arteries is challenging with a high rate of restenosis. Excimer laser atherectomy (ELA) has a theoretical advantage of ablating restenotic tissue and reducing or delaying the need for repeat revascularization. We present a retrospective analysis from our center on the outcomes of ELA in the treatment of in-stent restenosis of the FP arteries. Demographic, clinical, angiographic and procedural data were collected on all patients that underwent ELA for in-stent restenosis from February 2005 to April 2010 at a single medical center. Major adverse events and one-year target lesion revascularization (TLR) and target vessel revascularization (TVR) were obtained by reviewing of medical records. Descriptive analysis was performed on all variables. Kaplan-Meier survival curves for TLR were plotted. 40 consecutive patients (mean age 67.7±9.0years, 57.5% males) were included and followed for 1year. Adjunctive balloon angioplasty was performed in 100% at a mean pressure of 12.4±2.9atm. Acute procedural success (<30% angiographic residual narrowing) occurred in 92.5% of patients. Embolic filter protection (EFP) was used in 57.5% of patients. Bailout stenting was 50.0%. Macrodebris was noted in 65.2% of filters. The following adverse events were reported: distal embolization (DE) requiring treatment 2.5% (1 patient with no EFP); planned minor amputation 2.6%, planned major amputation 2.6%, total death 7.7% (all cardiac related). One perforation occurred treated successfully with stenting and balloon inflation. At one year, TLR and TVR occurred in 48.7% and 48.7% respectively. ELA has an overall favorable acute result in treating in-stent restenosis of the FP arteries. At one year TLR and TVR remain clinically significant. DE also occurs significantly with ELA and is effectively prevented with EFP.

Excimer laser with adjunctive balloon angioplasty and heparin‐coated self‐expanding stent grafts for the treatment of femoropopliteal artery in‐stent restenosis

The aim of the study is to evaluate the safety and effectiveness of treating femoropopliteal in-stent restenosis (ISR) with debulking with excimer laser followed by implantation of a VIABAHN endoprosthesis. The optimal treatment strategy for femoropopliteal ISR is unclear. The SALVAGE study is a multicenter prospective registry involving nine US centers. Patients with femoropopliteal ISR with moderate to severe intermittent claudication or critical limb ischemia (Rutherford categories 2-5) and an ankle-brachial index (ABI) =0.8 were treated with excimer laser and the VIABAHN endoprosthesis. The primary efficacy endpoint is primary patency at 12 months as measured by duplex ultrasonography. The primary safety endpoint is the major adverse event (MAE) rate at 30 days. Twenty-seven patients were enrolled. The mean lesion length was 20.7 ± 10.3 cm. The majority of lesions were TASC (TASC I) C and D (81.4%). All lesions were pretreated with excimer laser and percutaneous transluminal angioplasty (PTA) prior to VIABAHN implantation. Technical success was achieved in 100% of cases. There were no MAE at 30 days. Primary patency at 12 months was 48%. The ankle brachial index increased from 0.58 ± 0.24 at baseline to 0.90 ± 0.17 at 12 months. There was improvement in all quality-of-life parameters. The 12-month TLR rate was 17.4%. The strategy of excimer laser atherectomy and PTA followed by implantation of a self-expanding stent graft for the treatment of femoropopliteal ISR is safe and associated with high procedural success. Primary patency rate at 12-months was suboptimal; however, the TLR rate was low.

A prospective multicenter registry of laser therapy for degenerated saphenous vein graft stenosis: the COronary graft Results following Atherectomy with Laser (CORAL) trial

The primary aim of this study was to prospectively evaluate the safety and efficacy of Excimer laser atherectomy as a primary treatment strategy in consecutively eligible patients presenting for percutaneous coronary intervention (PCI) of degenerated saphenous vein graft (SVG) lesions using a multicenter registry. Prior single-center experience suggested that laser atherectomy may decrease acute procedural complications during treatment of degenerated SVGs, including lesions not amenable to distal protection devices (DPDs). The COronary graft Results following Atherectomy with Laser investigators enrolled 98 patients at 18 centers between June 23, 2003, and October 4, 2004, with greater than 50% stenosis of an SVG who presented for PCI due to angina pectoris or objective evidence of myocardial ischemia in a concordant myocardial distribution. Laser atherectomy was planned. Patients were excluded if the operator planned to utilize a DPD. Inclusion and exclusion criteria were aligned to those in the Saphenous vein graft Angioplasty Free of Emboli Randomized (SAFER) trial. The primary end point [30-day major adverse cardiac events (MACE)] occurred in 18/98 (18.4%) patients driven primarily by non-q-wave myocardial infarction. Major procedural complications included no reflow (n=5) and major dissection (n=1). No perforations occurred. Univariate predictors of 30-day MACE included lesion length, vessel angulation, plaque burden, SVG degeneracy score, number of laser pulses used, and larger-sized laser catheters. This study demonstrated that Excimer laser atherectomy of diseased SVGs is feasible with results comparable to the 30-day MACE in the control population from the SAFER trial. Whether the addition of laser to embolic protection devices is of any clinical utility remains to be tested in future studies.

Recanalization of Failed Autogenous Conduit Utilizing Laser Revascularization

The traditional approach for the treatment of restenosis of autogenous vein bypass has been revision of bypass with vein patch angioplasty, interposition jump graft, or thrombectomy procedures for those patients with extensive occlusive disease and limb-threatening ischemia. Endovascular intervention traditionally involves angioplasty of the graft; however, vessels with diffuse disease or extensive longitudinal lesions are generally difficult to revascularize utilizing this technique. Surgical revision of a threatened autogenous vein graft may carry a morbidity rate as high as 13.6%. We present a series of cases in which excimer laser atherectomy (LA) was used to recanalize an occluded autogenous saphenous vein bypass. Of the occluded vein bypasses failed angioplasty and were successfully atherectomized with LA measuring lengths of 35 and 30 cm, respectively. The infrainguinal has a 6-month follow-up, while the infragencular has a follow-up of 1 year, with resolution of presenting symptoms.

How should I treat severe calcific coronary artery disease?

An 80-year-old man with limiting angina pectoris. Physical examination, laboratory tests, echocardiography, exercise ECG, coronary arteriography, pressure wire assessment. Single severe calcific coronary artery disease. Elective percutaneous coronary intervention (PCI) for calcific mid-vessel stenosis with rotational and excimer laser atherectomy.

How should I treat severe coronary artery calcification when it is not possible to dilate a balloon or deliver a RotaWire™?

Background: A 61-year-old female with a history of type-II (tablet-controlled) diabetes, obesity and dyslipidaemia presented with chest pain and dyspnoea Investigation: Physical examination, electrocardiography, laboratory tests, coronary angiography Diagnosis: Single vessel coronary artery disease with severe calcification of a dominant right coronary artery Treatment: Excimer laser and rotational atherectomy.

Treatment of calcific coronary stenosis with the use of excimer laser coronary atherectomy and rotational atherectomy

Rotational atherectomy is the technique of choice for severe coronary artery calcification to facilitate adequate stent deployment. However, rotational atherectomy use is dependent on the delivery of a dedicated guide wire, which is not always achievable. We describe a series of five patients with severely calcified coronary lesions that were successfully treated with the combination of excimer laser and rotational atherectomy when it was not possible to deliver a RotaWire™ and use rotational atherectomy alone.

Predictors of failure and success of tibial interventions for critical limb ischemia

The efficacy of tibial artery endovascular intervention (TAEI) for critical limb ischemia (CLI) and particularly for wound healing is not fully defined. The purpose of this study is to determine predictors of failure and success for TAEI in the setting of CLI. All TAEI for tissue loss or rest pain (Rutherford classes 4, 5, and 6) from 2004 to 2008 were retrospectively reviewed. Clinical outcomes and patency rates were analyzed by multivariable Cox proportional hazards regression and life table analysis. One hundred twenty-three limbs in 111 patients (62% male, mean age 74) were treated. Sixty-seven percent of patients were diabetics, 55% had renal insufficiency, and 21% required hemodialysis. One hundred two limbs (83%) exhibited tissue loss; all others had ischemic rest pain. All patients underwent tibial angioplasty (PTA). Tibial excimer laser atherectomy was performed in 14% of the patients. Interventions were performed on multiple tibial vessels in 20% of limbs. Isolated tibial procedures were performed on 50 limbs (41%), while 73 patients had concurrent ipsilateral superficial femoral artery or popliteal interventions. The mean distal popliteal and tibial runoff score improved from 11.8 ± 3.6 to 6.7 ± 1.6 (P < .001), and the mean ankle-brachial index increased from 0.61 ± 0.26 to 0.85 ± 0.22 (P < .001). Surgical bypass was required in seven patients (6%). The mean follow up was 6.8 ± 6.6 months, while the 1-year primary, primary-assisted, and secondary patency rates were 33%, 50%, and 56% respectively. Limb salvage rate at 1 year was 75%. Factors found to be associated with impaired limb salvage included renal insufficiency (hazard ratio [HR] = 5.7; P = .03) and the need for pedal intervention (HR = 13.75; P = .04). TAEI in an isolated peroneal artery (odds ratio = 7.80; P = .01) was associated with impaired wound healing, whereas multilevel intervention (HR = 2.1; P = .009) and tibial laser atherectomy (HR = 3.1; P = .01) were predictors of wound healing. In patients with tissue loss, 41% achieved complete closure (mean time to healing, 10.7 ± 7.4 months), and 39% exhibited partial wound healing (mean follow up, 4.4 ± 4.8 months) at last follow up. Diabetes, smoking, statin therapy, and revascularization of > 1 tibial vessel had no impact on limb salvage or wound healing. Re-intervention rate was 50% at 1 year. TAEI is an effective treatment for CLI with acceptable limb salvage and wound healing rates, but requires a high rate of reintervention. Patients with renal failure, pedal disease, or isolated peroneal runoff have poor outcomes with TAEI and should be considered for surgical bypass.

Heavily Calcified Coronary Arteries: The Bane of an Interventionalist's Existence

(J Interven Cardiol 2010;23:254–255)

PS128. Outcomes of Excimer Laser Atherectomy for the Treatment of Infrainguinal Occlusive Disease in Patients With Critical Limb Ischemia

To evaluate outcomes of patients undergoing Excimer Laser atherectomy (ELA) for the treatment of infrainguinal occlusive disease in patients with critical limb ischemia. A retrospective review of all patients who underwent infrainguinal ELA for critical limb ischemia at Dartmouth-Hitchcock Medical Center from November 2005 to December of 2008 was performed. The primary outcome measure was limb salvage. Secondary outcomes included amputation free survival and freedom from reintervention. Data were analyzed using life table analysis. Fifty-two procedures were performed. The average patient age was 76 years, 73% had tissue loss. Fifty five percent had undergone prior interventions. The superficial femoral artery was treated in 47% of cases, the popliteal artery in 25% and the tibial arteries in 28%. Sixty-five percent of treated lesions were occlusions; with 41 percent of lesions being TASC C and 43 percent TASC D lesions. Median follow-up was 14-months (range 2-days to 43-months). Overall technical success was achieved in 92%. Transluminal angioplasty or stent deployment was required for residual stenosis or dissection following ELA in 85% percent of cases. Technical complications occurred in 10 patients (19%). Distal embolization occurred in 2 cases, arterial perforation in 3 cases and dissection in 5 cases. Ipsilateral limb salvage was 75% at one year and amputation free survival rate was 65%. Freedom from reintervention was 54% at one year, and 10 (20%) patients went on to require lower extremity bypass. ELA can be used safely with a high degree of success for treatment of multilevel infrainguinal arterial disease, though it is not sufficient as stand alone therapy. While reasonable limb salvage rates can be achieved, long-term patency is difficult to maintain and warrants careful follow-up.

Retrograde Transpopliteal Recanalization of Chronic Superficial Femoral Artery Occlusion After Failed Re-Entry During Antegrade Subintimal Angioplasty

To evaluate the acute success and clinical impact of retrograde transpopliteal access for subintimal recanalization of superficial femoral artery (SFA) and proximal popliteal artery (PA) occlusions after failed attempts to re-enter the true lumen in the antegrade femoral approach. From 2002 to 2007, 56 patients (43 men; mean age 68+/-9 years, range 43-87) with stable chronic peripheral artery disease (Rutherford category 2 to 5) were treated with antegrade subintimal angioplasty that could not be completed owing to re-entry failure. Mean occlusion length was 17+/-7 cm (range 4-32), including 13 TASC II A (23.2%), 10 TASC II B (17.8%), 16 TASC II C (28.5%), and 17 TASC II D (30.3%) lesions. After re-entry to the true lumen failed in the antegrade approach, including predilation of the false channel, all patients were turned to a prone position, and a 5-F or 6-F sheath was placed into the mid segment of the PA under fluoroscopic guidance. Retrograde wire passage was attempted with a 0.035-inch hydrophilic guidewire. Fifty-five (98.2%) of 56 procedures were finished successfully with a residual stenosis of <30%; the 1 failure was due stent deformation within the occluded segment that could not be passed from either an antegrade or retrograde access. In all interventions, balloon angioplasty was performed; provisional stenting was done in 40 (71.4%). In 3 (5.3%) lesions, additional excimer laser atherectomy were performed. Six (10.7%) complications occurred, including 1 arteriovenous fistula from the PA to the popliteal vein and 1 sealing device induced PA occlusion. The mean ankle-brachial index increased from 0.44+/-0.26 to 0.86+/-0.23. The restenosis rate after 12 months was 54.9%. Failed antegrade attempts to recanalize chronic total occlusions of the SFA and proximal PA can be salvaged using a retrograde popliteal access, with a low complication rate, as an alternative to using a re-entry device. However, durability of the intervention using current interventional tools is limited.