Subintimal recanalisation of long SFA occlusion using a reentry device (the movie)

Clinical History

Critical limb ischaemia (Rutherford class 6) of the left leg in a lady in general poor condition with chronic renal failure and diabetes. CDUS revealed an occlusion of the left superficial femoral artery (SFA). An attempt to recanalise the occlusion was required.

Imaging Findings

The preliminary angiogram revealed a long occlusion of the SFA (2-3 cm after the origin, Fig.1a) with late revascularisation of the distal SFA through collaterals (Fig.1b). Very poor and late vascularisation of the below-the-knee vessels was observed (Fig.1c). Several attempts to pass the occlusion with the guidewire were done: all of that in the subintimal space without re-entry into the true lumen. For this reason we tried with the Outback Re-Entry-Device (ORD), which was advanced over a .014" wire (Fig.2-movie), to reach the intraluminal position distally to the occlusion. Before puncture of the intima layer the C-arm was rotated until the distal markers were correctly seen (Fig. 3). At second attempt the needle of catheter penetrated the intima and the wire advanced easily in the true lumen (Fig.4, 5-movies). We performed several balloon angioplasties (Fig.6), with a quite satisfactory result. To achieve an optimal result two stents were deployed (Fig.7). The final angiogram showed a successful recanalisation (Fig.8).

Discussion

Re-entry devices are reliable tools to recanalise challenging chronic femoropopliteal occlusions after failed guide-wire re-entry. The first devices introduced in the clinical practice were the Outback Re-Entry Device (www.cordis.com) and the Pioneer catheter (www.medtronic.com) [1]. The ORD appears quite simple to use: once chosen the re-entry level, you have to rotate the C-arm and look at the tip of the device and see the “inverted T” and “L” radiopaque marker directed towards the lumen (Fig. 3). At this point the angled needle is pushed (Fig. 4-movie) and the intima layer is perforated: now a .014” wire can be advanced in the lumen (Fig. 5-movie). One of the first case series using the Outback catheter was reported by Zeller T et al [2] on 65 legs in 61 patients with chronic occlusion of the SFA and proximal popliteal artery. In all cases, the true lumen could not be entered by using standard antegrade catheter and guide wire techniques. Recanalisation of the arterial occlusion was successful in 57 of 65 treated lesions (88%). More recently (2011) Schmidt et al [3] reported their experience with the ORD to recanalise the femoropopliteal chronic total occlusions in 118 limbs of 113 patients. In their experience the re-entry was accomplished in 108/118 limbs (91.5%) with recanalisation completed in 107/118 (90.7%). After 12 months, primary patency was 56.7%, assisted primary patency 83.1%, and secondary patency 89.1%. Both papers conclude that the ORD is a reliable tool to recanalise challenging chronic femoropopliteal occlusions after failed guidewire re-entry. However, restenosis rates are high, due to the severity and extent of disease in these patients, who are particularly challenging. Although the device does not appear particularly complex to use the results are not so uniform and some authors report lower percentage of success than previously cited. In the experience of Shin et al (2011) re-entry was successful in 34 attempts (64.5%). Causes of failure included inability to re-enter the true lumen in 11 (61.1%), difficulty tracking the device over a wire in 3 (16.7%), acute angle of aortic bifurcation in 2 (11.1%), mechanical failure of the device in 1 (5.6%), and difficulty tracking the device through the lesion in 1 (5.6%). Moderate or severe calcification at the site of re-entry was the only significant predictor of failure.

Differential Diagnosis List

Final Diagnosis

Subintimal recanalisation of long SFA occlusion with a re-entry device

URL:	https://www.eurorad.org/case/10556
DOI:	10.1594/EURORAD/CASE.10556
ISSN:	1563-4086