Teaching Case

Total occlusion of left popliteal artery

The patient was admitted with a non-healing ulcer of his left foot representing stage IV (Fontaine´s classification) peripheral arterial disease. Angiography (Fig. 1) revealed a total occlusion of the left popliteal artery at the level of the knee joint. Percutaneous revascularization was recommended.

Selective catheterization of the superficial femoral artery was performed via an ipsilateral antegrade common femoral artery puncture. A multipurpose catheter was advanced o the popliteal artery and passage of the occlusion was tried by use of a straight guide wire. Due to a calcified plaque at the proximal level of the occlusion, entry into the occluded lumen was not achieved. Thus, a subintimal channel was created by the angulated multipurpose catheter and the tip of the guidewire was inserted into the subintimal channel. By forming a loop of the catheter´s tip this loop was advanced towards the distal end of the occlusion ( Fig. 2 a, b) where the true lumen was reentered by use of the catheter and the guidewire. Balloon angioplasty with use of a 4 mm large , 4 mm long balloon was performed within the subintimal channnel, resulting in a recanalized lumen at the level of the previous occlusion (Fig. 2 c). Intentional subintimal recanalization is a technique that was first described by Bolia in order to overcome long-segment occlusions which are not able to be recanalized by other means. This technique is feasible to be applied to the femoropopliteal but also to the subpopliteal arteries. The main complication is destruction of important collateral arteries while not achieving a successful reentry into the true lumen which could worsen the vascular situation. The technique is mainly recommended in cases with limbs at risk (stage III and IV Fontaine). There is no place for that type of treatment in fresh occlusions Follow-up results have been described as sufficient concerning limb salvage and reobstruction. Since only few centers perform this technique on a routine base, large statistical data are scarce. With no doubt, some of our successful recanalizations which were intended to be within the true lumen are running in a subintimal but unintentionally created neolumen.