Re-entry Catheter Research Articles

Recanalization of Chronic Femoropopliteal Total Occlusions after Failed Anterograde Attempt: Use of an Intravascular Ultrasound–Guided Re-entry Catheter versus the Bidirectional Approach

PurposeTo analyze the feasibility and effectiveness of the use of an intravascular ultrasound (IVUS)–guided re-entry catheter (IGRC) for femoropopliteal chronic total occlusions (FP-CTOs) after a failed anterograde approach compared with the bidirectional approach without the IGRC. Materials and MethodsBetween June 2019 and December 2022, an IGRC (Pioneer Plus; Philips Volcano, San Diego, California) was used in 52 patients after failure of conventional recanalization techniques (Group A). In the same period, 48 patients who were also eligible for IGRC use were treated without IGRC using the bidirectional approach (Group B). In Groups A and B, 12 (23.1%) and 3 (6.2%) patients experienced claudication, and 40 (76.9%) and 45 (93.7%) patients experienced critical limb-threatening ischemia, respectively. Clinical and procedural records, angiographic imaging findings, and follow-up data were collected, analyzed, and reviewed. ResultsTechnical success was achieved in 49 (94.2%) patients in Group A and 44 (91.7%) patients in Group B (P = .616). Use of the IGRC was associated with a reduction of procedural time (120 vs 133 minutes; P < .001), radiation exposure (47 vs 59 Gy cm2; P < .001), iodinated contrast medium use (98 vs 138 mL; P = .028), and intraprocedural discomfort (numerical rating scale score, 4 vs 6; P < .001). ConclusionsUse of the IGRC was equivalently successful for FP-CTO recanalization compared with the use of the bidirectional approach, but it reduced radiation exposure, iodinated contrast medium used, patient discomfort, and procedural time. These advantages suggest that IGRC could be favored as the next-choice option for FP-CTOs after failure of anterograde recanalization.

Comparative analysis of re-entry malecot and nelaton catheters after standard percutaneous nephrolithotomy in adult patients: a cross-sectional study.

Drainage catheters are used almost routinely to provide urinary drainage, prevent extravasation of urine, and create tamponade against bleeding after percutaneous nephrolithotomy (PNL). In the literature, there is no standardized approach to determining which type of catheter is superior. In this context, we aimed to comparatively analyze two different types of catheters (re-entry malecot catheter and nelaton catheter) in terms of success and complications, which we use for drainage after a PNL operation and which have very different costs. Patients who underwent PNL for kidney stones between January 2018 and October 2022 were included in the study. The data of a total of 148 patients who had a 16-F reentry malecot nephrostomy catheter or a 16-F nelaton catheter were analyzed. In addition to the demographic characteristics of the patients, stone characteristics, operative data, hospitalization time, analgesia requirement, hemoglobin exchange, amount of blood transfusion, and postoperative data (success and complications) were comparatively evaluated. The current unit price for a reentry malecot and a nelaton catheter is 4.7 United States dollars (USD) and 0.11 USD, respectively. There were a total of 148 patients in the study, 63 of whom were nelaton catheters and 85 were reentry malecots, and the mean age was 39.95 ± 13.28years. There was no statistically significant difference between preoperative stone sizes and residual stone rates according to the groups. In addition, there was no statistically significant difference between the groups in terms of access site and stone localization. There was no significant difference between the groups in terms of complication rates according to the Clavien-Dindo classification, Hb levels, blood transfusion rates, operation times, or hospitalization times. In conclusion, if a second procedure is planned, a reentry malecot catheter may be preferred. Apart from this situation, nelaton catheters should be preferred because they are similar to reentry catheters in terms of effectiveness, and side effects and are more economical than reentry catheters in terms of cost.

Endovascular revascularization of chronically occluded common carotid artery for symptomatic cerebral hypoperfusion.

Endovascular recanalization is increasingly being utilized in symptomatic patients with chronically occluded carotid arteries.1 In carefully selected patients, endovascular recanalization has shown to lower the risk of ischemic events when compared to medical management alone.1 However, successful endovascular revascularization is technically challenging and not without risk.1, 2 In this video, we demonstrate a case of a 64-year-old woman who presented with recurrent transient ischemic attacks. On imaging she was found to have a chronic total occlusion of the common carotid artery from the arch. After obtaining informed consent, the patient underwent a successful endovascular recanalization and stenting of a chronically occluded left common carotid artery with aid from an intravascular guided re-entry catheter. Post operatively the patient developed a neck hematoma which improved and she returned to her neurological baseline. She reported no further symptoms on her three month follow up.

Relining of a Bridging Covered Stent to Treat a Rare Cause of Type IIIc Endoleak Following Fenestrated Endovascular Aneurysm Repair.

To present a rare cause of type III endoleak via the left renal artery (LRA) fenestration following fenestrated endovascular aneurysm repair (FEVAR) and to describe a successful reintervention for treating this endoleak. The patient presented with a type IIIc endoleak following FEVAR, due to inadvertent placement of the LRA bridging balloon expandable covered stent (BECS) via the superior mesenteric artery (SMA) fenestration, but deployed outside the SMA fenestration. The proximal part of the BECS was positioned outside of the main body. This caused a type IIIc endoleak via the open LRA fenestration. Reintervention was performed by relining the LRA with a new BECS. First, access to the lumen of the previously placed BECS was gained using a re-entry catheter, followed by placement of a new BECS via the LRA fenestration. Completion angiography, and computerized tomography angiography (CTA) at 3 months follow-up showed total obliteration of the endoleak and patency of the LRA. Placement of a bridging stent via an incorrect fenestration during FEVAR is a rare cause of type III endoleak. In certain cases, successful treatment of such an endoleak could be achieved by perforation and relining of the misplaced BECS via the correct fenestration of the target vessel. To our best knowledge, a type IIIc endoleak following fenestrated endovascular aneurysm repair, due to placement of a bridging covered stent through an incorrect fenestration and deployed short of the fenestration, has not been described before. Reintervention was performed with perforation of the previously placed covered stent and relining using a new bridging covered stent. The technique presented here was successful for treating the endoleak in this case and could help guide clinicians when dealing with this or similar complications.

Target Balloon-Assisted Antegrade and Retrograde Use of Re-Entry Catheters in Complex Chronic Total Occlusions.

We report data from a retrospective multicenter registry. Eligibility criteria included either antegrade or retrograde use of the OutbackTM or GoBackTM re-entry catheter in combination with a balloon as a target to accomplish wire passage, when conventional antegrade and retrograde recanalization attempts had been unsuccessful. Procedural outcomes included technical success (defined as wire passage though the occlusion and delivery of adjunctive therapy with <30% residual stenosis at final angiogram), safety (periprocedural complications, e.g., bleeding, vessel injury, or occlusion of the artery at the re-entry site, and distal embolizations), and clinical outcome (amputation-free survival and freedom from target lesion revascularization after 12-months follow-up). Thirty-six consecutive patients underwent target balloon-assisted recanalization attempts. Fourteen (39 %) patients had a history of open vascular surgery in the index limb. Fifteen patients were claudications (Rutherford Class 2 or 3, 21 presented with chronic limb threatening limb ischemia (Rutherford Class 4 to 6). The locations of the occlusive lesions were as follows: iliac arteries in 3 cases, femoropopliteal artery in 39 cases, and in below-the-knee arteries in 12 cases. In 15 cases, recanalization was attempted in multilevel occlusions. Retrograde access was attempted in 1 case in the common femoral artery, in the femoropopliteal segment in 10 cases, in below-the-knee arteries in 23 cases, and finally in 2 patients via the brachial artery. In 10 cases, the re-entry devices were inserted via the retrograde access site. Technical success was achieved in 34 (94 %) patients. There were 3 periprocedural complications, none directly related to the target balloon-assisted re-entry maneuver. Amputation-free survival was 87.8 % and freedom from clinically driven target lesion revascularization was 86.6 % after 12-months follow-up. Target balloon-assisted use of re-entry devices in chronic total occlusions provides an effective and safe endovascular adjunct, when conventional antegrade and retrograde recanalization attempts have failed.

Re-entry catheters in subintimal lower limb recanalization: up to date.

In their daily practice, vascular specialists face the challenge of treating peripheral artery disease (PAD) of the lower limbs. During the last decade, there has been an increasing adoption of endovascular techniques worldwide and a simultaneous expansion of the endovascular instrument portfolio to improve technical results during PAD treatment. The proper use of dedicated endovascular devices is essential to achieve technical success. To know indication, mechanism of action, and possible complications of different devices is of paramount importance to achieve immediate procedural success in the shortest time possible and long-term patency of the treated vessels. All the re-entry catheters on the market are presented with their own unique characteristics. The pros and cons of the use of these devices is also discussed and compared to other possible recanalization strategies. The re-entry devices have been demonstrated to be effective in increasing the procedural success rate, in limiting the dissection of distal healthy vessel segments and shortening the procedural time. They should therefore be considered part of essential tools in the treatment of lower limb chronic total occlusions especially for clinicians who do not feel comfortable in performing retrograde access.

Efficacy and safety of percutaneous nephrolithotomy in elderly patients: Experience of 128 cases

OBJECTIVE: This study aimed to evaluate the efficacy and safety of percutaneous nephrolithotomy in elderly patients (≥65 years) with kidney stones &gt; 2 cm in size.&#x0D; PATIENTS AND METHODS: Patients aged ≥65 years who underwent percutaneous nephrolithotomy for kidney stones between January 2015 and January 2022 were included in this study. Patient profiles, preoperative stone data, operative information, and postoperative complications were reviewed. We applied the Guys Stone score to predict the net results of percutaneous nephrolithotomy.&#x0D; RESULTS: Percutaneous nephrolithotomy was performed on 128 geriatric patients. Of these patients, 68 (53.1%) were male and 60 (46.9%) were female. The mean age was 69.87 ± 7.06 (65–80) years. The mean stone size was 28.7 ± 6.5 mm (22–46 mm). The mean operative time was 90.33 ± 40.56 min and fluoroscopy time was 5.16 ± 2.81 min. The reentry catheter was removed after an average of 3.21 ± 1.82 days. The mean duration of hospital stay was 3.17 ± 2.19 days. The stone-free survival rate was 90.6%. Transfusion was performed in four (3.1%) patients due to hemorrhage, and urine extravasation from the re-entry tract occurred in eight (6.2%) patients, and this required Double j-stent placement. When the four Guys stone score groups were compared, there was a statistically significant difference in stone-free rates (p = 0.001).&#x0D; CONCLUSIONS: According to our results, percutaneous nephrolithotomy is a safe and effective treatment option for nephrolithiasis in the elderly, with high stone-free and acceptable complication rates.

Color-coded summation images for the evaluation of blood flow in endovascular aortic dissection fenestration

BackgroundTo analyze the benefit of color-coded summation images in the assessment of target lumen perfusion in patients with aortic dissection and malperfusion syndrome before and after fluoroscopy-guided aortic fenestration.MethodsBetween December 2011 and April 2020 25 patients with Stanford type A (n = 13) or type B dissection (n = 12) and malperfusion syndromes were treated with fluoroscopy-guided fenestration of the dissection flap using a re-entry catheter. The procedure was technically successful in 100% of the cases and included additional iliofemoral stent implantation in four patients. Intraprocedural systolic blood pressure measurements for gradient evaluation were performed in 19 cases. Post-processed color-coded DSA images were obtained from all DSA series before and following fenestration. Differences in time to peak (dTTP) values in the compromised aortic lumen and transluminal systolic blood pressure gradients were analyzed retrospectively. Correlation analysis between dTTP and changes in blood pressure gradients was performed.ResultsMean TTP prior to dissection flap fenestration was 6.85 ± 1.35 s. After fenestration, mean TTP decreased significantly to 4.96 ± 0.94 s (p < 0.001). Available systolic blood pressure gradients between the true and the false lumen were reduced by a median of 4.0 mmHg following fenestration (p = 0.031), with significant reductions in Stanford type B dissections (p = 0.013) and minor reductions in type A dissections (p = 0.530). A moderate correlation with no statistical significance was found between dTTP and the difference in systolic blood pressure (r = 0.226; p = 0.351).ConclusionsHemodynamic parameters obtained from color-coded DSA confirmed a significant reduction of TTP values in the aortic target lumen in terms of an improved perfusion in the compromised aortic region. Color-coded DSA might thus be a suitable complementary tool in the assessment of complex vascular patterns prevailing in aortic dissections, especially when blood pressure measurements are not conclusive or feasible.

Retrograde use of the Outback re-entry catheter in complex infrainguinal arterial recanalizations.

Retrograde recanalizations gained increasing recognition in complex arterial occlusive disease. Re-entry devices are a well-described adjunct for antegrade recanalizations. We present our experience with retrograde, infrainguinal recanalizations using the Outback re-entry catheter in challenging chronic total occlusions. We report data from a retrospective multicenter registry in complex retrograde recanalizations. Eligibility criteria included retrograde infrainguinal use of the Outback re-entry catheter where both conventional antegrade and retrograde recanalizations had been unsuccessful. Procedural outcomes included technical success (defined as successful wire passage and delivery of adjunctive therapy with<30% residual stenosis), safety (periprocedural complications, eg, bleeding, vessel injury, or occlusion of the artery at the re-entry site, and distal embolizations), and clinical outcome (amputation-free survival and freedom from clinically driven target lesion revascularization [cd-TLR]). Forty-five consecutive patients underwent retrograde, infrainguinal recanalization attempts with the Outback re-entry catheter between February 2015 and August 2020. Thirty (67%) patients had a history of open vascular surgery in the index limb. In four patients, recanalizations were even more challenging due to previous surgical removal and/or ligation of the proximal segment of the superficial femoral artery. The retrograde access site of the Outback catheter was the femoropopliteal segment in 31 (69%) patients and crural vessels in 14 (31%) patients. The re-entry target sites were as follows: common femoral artery in 31 (69%) patients, superficial femoral artery in 9 (20%) patients, popliteal artery in 1 patient, and below-the-knee arteries in 2 patients. In four patients, the needle of the re-entry device was targeted to an inflated balloon, inserted via the antegrade route. The Outback re-entry catheter was placed via a 6-French sheath in 19 (42%) cases and sheathless in 26 (58%) cases. Technical success was achieved in 41 (91%) patients There were two instances of distal embolizations and three bleeding episodes. Amputation-free survival was 100% at 30days, and after 12months, freedom from cd-TLR was 95% at 30days and 75% at 12months of follow-up. Female sex was an independent predictor for cd-TLR at 12months of follow-up. Retrograde use of the Outback re-entry catheter in infrainguinal chronic total occlusions provides an effective and safe endovascular adjunct, when conventional antegrade and retrograde recanalization attempts have failed.

Fusion imaging guidance for endovascular recanalization of peripheral occlusive disease

ObjectiveEndovascular procedures are now the first line option for treatment of lower extremity arterial disease. Fusion imaging guidance has been reported to reduce radiation exposure and reintervention rates during fenestrated and branched endovascular repairs, but limited literature exists on its benefits during lower extremity arterial disease endovascular procedures, and more specifically peripheral occlusive disease (POD). This study aims to evaluate the radiation exposure and technical success benefits of fusion imaging guidance in a large cohort of patients treated endovascularly for complex POD. MethodsFrom January 2017 to September 2019, in a single center, all consecutive patients presenting symptomatic occlusions (Rutherford Baker categories 3 to 6) in the setting of POD and treated endovascularly were retrospectively assessed for inclusion. All procedures were performed under augmented fluoroscopy guidance (Vessel ASSIST, GE Healthcare), overlaying on live imaging the 3D path for transluminal recanalization based on the preoperative computed tomography angiography. Technical success, dose area product (DAP), total cumulated air kerma (CAK), and fluoroscopy time were collected. DAP results were compared with the literature. ResultsDuring the study period, 179 patients were treated for iliac (n = 56) or femoropopliteal (n = 123) symptomatic arterial occlusions. Technical success was reported in 171 of 179 procedures (95.5%). The use of a re-entry catheter was required to achieve technical success in 11 patients (6.1%). Mean DAP and CAK were 12.70 Gy·cm2 and 135 mGy, respectively, with a mean fluoroscopy time of 15.26 minutes. DAP and CAK were significantly higher in the iliac group when compared with the femoropopliteal group, although fluoroscopy time was not significantly different. DAP was lower than levels reported in the literature. ConclusionsRoutine use of fusion imaging guidance during POD endovascular treatment is associated with low radiation exposure, high technical success, and reduced need for re-entry systems.

Management of Subintimal Position of Kissing Stents using Re-entry Catheter with Cone Beam-Computed Tomography Image Overlaid onto Live Fluoroscopy

Background Several endovascular or surgical treatments have been proposed to treat total chronic occlusions of the iliac bifurcation. Nowadays, endovascular options are considered as a first choice because of the decreased per-operative morbi-mortality. Nevertheless, unexpected intraoperative events may occur, such as dissection or rupture of the iliac artery. We report a case of inadvertent bilateral false lumen kissing stents positioning, rescued with stents extensions guided with image fusion guidance. Case presentation A 60-year-old male patient referred to our Department because of a severe bilateral claudication, 8 months after an iliac kissing stent for common iliac arteries occlusion. A CT angiography (CTA) was performed, showing a bilateral dissection of the aorto-iliac bifurcation at the proximal part of the stents, which were placed into the false lumen whereas the distal part was into the true lumens (TL). Lower limb perfusion was maintained by inferior mesenteric and hypogastric arteries. As a CTA performed before the first endovascular intervention showed no dissection of the aortic bifurcation, the flaps were probably created during the previous interventions. An endovascular revision was planned. After a bilateral femoral access, the proximal part of the flap was pierced with a needle-based re-entry device, deployed under three-dimensional cone-beam CT image overlay with bi-planar fluoroscopy. The lumen patency was then restored with stents extensions up to the renal ostia. The final angiography showed stents patency. No complication occurred during the intervention. The patient was dismissed the day after, with good arterial femoral pulse and no further complications. An US color Doppler performed one month after the intervention showed satisfactory blood flow of both iliac and femoral arteries as well as a good flow in the lower limbs. Conclusions The integration of modern 3D image guidance and novel endovascular devices allows the management of adverse events with a minimally-invasive approach.

Novel Experimental Technique to Create Size-Controlled Retroperitoneal Bleeding in the Infrarenal Aorta of Anesthetized Pigs.

Rupture of abdominal aortic aneurysm (rAAA) with a contained retroperitoneal hematoma is potentially fatal. Physiological studies are difficult to perform in patients suffering from life-threatening conditions such as rAAA. A translational model of the condition is therefore needed. The aim was to develop and validate an endovascular animal model for retroperitoneal bleeding of the abdominal aorta with contained hematoma. In anesthetized pigs, a puncture hole was made in the posterolateral portion of the infrarenal aorta by an Outback re-entry catheter device. The hole was gradually enlarged using angioplasty balloons to a specific diameter of either 4 mm (n = 6), 6 mm (n = 7), or 8 mm (n = 6). Onset of bleeding was verified by angiography and macroscopically examined on completion of the experiments. Survival up to 180 min was the primary outcome. Hemodynamic and metabolic markers in arterial blood were secondary outcomes. Aortic injury with a contained retroperitoneal hematoma was achieved in all animals. Survival rate at 180 min after onset of bleeding was higher in the 4 mm group compared to the 6 mm (P = 0.021) and 8 mm groups (P = 0.002), but not when comparing the 6 mm and 8 mm groups. Systemic hypotension, arterial acidosis, and lactatemia were provoked in the 6 mm and 8 mm groups but not in the 4 mm group. A porcine model for a controlled contained left posterolateral retroperitoneal bleeding was created using endovascular methods and validated. This model makes it possible to study the pathophysiology of a retroperitoneal hematoma.

The Outback Re-Entry Device. A Pictorial Review.

The Outback™ Elite re-entry catheter (CORDIS, Cardinal Health, USA) is designed to facilitate placement and positioning of guidewires within the peripheral vasculature and allows for re-entry of a guidewire back into the true lumen of a vessel following a subintimal crossing of an arterial occlusion. The device was first introduced in 2005 and has become widely utilized in a variety of situations involving both arterial and venous interventions. This article aims to share our experiences with the Outback™ device and inform interventionalists of its utility and versatility.

Distal Re-Entry to Treat Lower Limb Chronic Total Occlusions Using a Novel Electrically Guided Re-Entry Catheter

IntroductionEndovascular treatment of challenging infra-inguinal peripheral vascular disease is increasingly common because of new techniques and improved tools. The use of a novel electrically guided 5 F re-entry catheter is presented. By emitting a minute electrical field, detected by a target wire inserted from an opposing access, the catheter's orientation is accurately displayed to the operator, allowing precise re-entry without the need for fluoroscopic alignment.ReportAn 84 year old man with tissue loss was treated for a long occlusion of the superficial femoral artery and tibial vessels. Successful subintimal recanalisation was achieved with the help of the ePATH re-entry catheter, restoring inline flow to the foot.ConclusionThis re-entry catheter benefits from an intuitive alignment method, smaller profile, and operator adjustable needle travel, making it a versatile tool for endovascular cases.

Intravascular Ultrasound–Guided Revascularization of Chronic Juxtarenal Aortoiliac Occlusion

Chronic juxtarenal aortoiliac occlusion (JRO) represents the most severe form of aortoiliac occlusive disease, classified under Trans-Atlantic Inter-Society Consensus (TASC II) as a TASC II D lesion with surgical treatment as the main recommendation. Although endovascular revascularization of other TASC II D lesions are routinely performed, JRO is often considered a contraindication for endovascular treatment due to the extensive nature, extending from the level of the renal arteries down to the iliac arteries. We hereby illustrate an intravascular ultrasound-guided re-entry based technique to facilitate endovascular reconstruction of a JRO. A 58-year-old man with JRO presented with an infected nonhealing forefoot ulcer. A transradial pigtail catheter was positioned at the level of the occlusion as an imaging catheter and landmark for re-entry. Subintimal wiring was performed through bilateral groin accesses to the level of the pigtail catheter. Intravascular-guided re-entry catheter was used to identify the true lumen guide firing of the needle catheter, allowing passage for a guidewire into the true lumen of the suprarenal aorta. The intimal fenestration was dilated using a 4-mm angioplasty balloon which allowed passage of the contralateral guidewire. Kissing stent grafts were deployed bilaterally, extending from the level of the infrarenal aorta down to the level of the distal external iliac arteries in overlapping fashion. Completion angiography showed brisk flow from the aorta through the stented portion into the femoral arteries. The patient underwent forefoot amputation 2 days later with successful wound healing and limb salvage at 6months.

LEA 38. Retrograde Use of the Outback Re-entry Catheter in Complex Infrainguinal Arterial Recanalization

The objective of this study was to demonstrate the efficacy and safety of the Outback (Cordis, Santa Clara, Calif) re-entry catheter in complex retrograde subintimal infrainguinal arterial recanalization for patients affected by critical limb ischemia. Between 2015 and 2019, the Outback re-entry catheter was used to re-enter the true lumen in 29 patients with critical limb ischemia who underwent retrograde superficial femoral artery, with or without popliteal artery subintimal recanalization, after failed guidewire and catheter-assisted re-entry. The retrograde access site was distal superficial femoral artery in 21 patients, proximal anterior tibial artery in 5 patients (Fig 1), and proximal peroneal artery in 3 patients. The re-entry target was common femoral artery in 27 patients, proximal superficial femoral artery in 1 patient, and proximal anterior tibial artery in 1 patient. Technical success was 89% (26/29). In all the successful cases, the re-entry was accurate (Fig 2), without damage to the profunda femoral artery. In 25 of 26 successful cases, the lesion was stented after plain balloon angioplasty. Supera (Abbott, Abbott Park, Ill) stent (with the proximal one always deployed from the retrograde access) was the most commonly used stent in 19 cases. The Outback was inserted through a 6F sheath in 13 cases and without any sheath in 16 cases (always when the retrograde access was at the level of below-knee vessels), passing the device over a 0.018-inch guidewire. In all cases, there were no significant complications correlated to the retrograde access. The use of the Outback re-entry catheter after complex retrograde subintimal infrainguinal recanalization has been demonstrated to be effective and safe. The possibility of passing it over a 0.018-inch guidewire gives the chance of doing it without inserting a sheath, reducing the size of the access and possible complications.Fig 2Precise re-entry obtained at the level of the short superficial femoral artery stump and at the anterior tibial origin in two different cases, with wire always eventually passed into the sheath coming from the antegrade access.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

03:45 PM Abstract No. 18 Arterial recanalization using the Outback LTD re-entry catheter in chronic lower extremity occlusions

Revascularization of arterial chronic total occlusions (CTO’s) can result in a subintimal course, requiring true lumen re-entry to establish antegrade flow. Here we report a retrospective study investigating the efficacy of the low profile OUTBACK® LTD re-entry catheter (Cordis, Milpitas CA) in above and below the knee subintimal recanalization of CTO’S when conventional techniques fail. Single-center review of lower extremity revascularizations between March 2013 and July 2018 using the 6 Fr OUTBACK® LTD catheter was conducted. The catheter was used in a total of 58 patients (37 male, mean age 72.3±12.2) with CTO’s. Vascular claudication was the primary indication in 17.2% (10/58) of patients, while critical limb ischemia (CLI) (72.4%, 42/58) accounted for the remainder. 60.3% (35/58) of occlusions were suprapopliteal, while the remaining 39.7% (23/58) were at or below the level of the popliteal artery including the proximal tibial arteries. If conventional recanalization methods were unsuccessful, the catheter was utilized in an antegrade or retrograde fashion to gain re-entry beyond the occlusion in the subintimal space. Technical success rate of re-entry into the true lumen, achievement of arterial patency, and major/minor complication rate were evaluated. The catheter successfully achieved true lumen re-entry beyond the occlusion at a rate of 86.2% (50/58). Final intervention was then performed with balloon angioplasty and/or stenting in 96% (48/50) as deemed appropriate; two failures were due to intraprocedural thrombosis of the recanalized artery. No significant difference was observed when assessing the rate of true lumen re-entry by site of occlusion (29/35 suprapopliteal occlusions vs 21/23 occlusions at or below the level of the popliteal artery, p=0.458). The observed minor complication rate was 10.3% (4 thromboses, 1 postprocedural hematoma, 1 dissection). No major complications were observed. If conventional recanalization methods are unsuccessful, the OUTBACK® LTD catheter is safe and effective in achieving luminal re-entry for subsequent recanalization in lower extremity arterial chronic total occlusions, independent of occlusion site.

TCTAP C-213 Successful Endovascular Treatment of Chronic Total Superficial Femoral Artery Occlusion Using a Side-hole Sheath and Re-entry Catheter

TCTAP C-213 Successful Endovascular Treatment of Chronic Total Superficial Femoral Artery Occlusion Using a Side-hole Sheath and Re-entry Catheter

Subintimal angioplasty for lower limb arterial chronic total occlusions.

Subintimal angioplasty for lower limb arterial chronic total occlusions.

Extravascular Revascularization of a Chronic Total Occlusion Using the Dual Bull’s-Eye Technique

Purpose: To describe the dual bull’s-eye technique to achieve successful extravascular revascularization of an occlusion after vessel perforation when the antegrade and retrograde catheters are too far apart for salvage with a reentry catheter. Technique: The dual bull’s-eye technique, which is an adaptation of the “gun-sight” method for transjugular portosystemic shunt procedures, is demonstrated in a popliteal artery occlusion in which multiple recanalization attempts have produced vessel perforation. Via antegrade femoral and retrograde anterior tibial artery accesses, 10-mm Amplatz GooseNeck snares were advanced in plane from each access to rendezvous in the popliteal fossa to obtain through-and-through wire access. A 15-cm Chiba needle was advanced percutaneously in plane through both snares, and a hydrophilic guidewire was maneuvered across an extravascular tract parallel to the popliteal artery. The tract was carefully predilated, and a 5×100-mm Viabahn stent-graft was deployed across the extravascular tract. Conclusion: Owing to potential complications (limited patency, injury to adjacent structures) and only single-case use, this new technique should be considered a bailout strategy exclusively employed for limb salvage when traditional methods have failed and there are no viable surgical options.