Strategies for Successful Percutaneous Revascularization of Chronic Total Occlusion of the Femoropopliteal Arteries When the Antegrade Passage of a Guide Wire Fails

Abstract

ObjectiveTo evaluate the efficacy of various strategies for revascularization of chronic total occlusion of femoropopliteal arteries when the guide wire does not pass in an anterograde direction.Materials and MethodsTwenty-four patients with totally occluded femoropopliteal arteries (mean occlusion length 13.75 cm; range, 6-22 cm) were treated by using a retrograde approach and two novel catheters. After successful recanalization or reentry, balloon angioplasty followed by stent placement was performed to complete the revascularization.ResultsIn 16 cases in which to cross the occlusion via intraluminal or subintimal route was failed, we used Frontrunner catheters in five cases and Outback catheters in 11 cases. In eight cases in which to reenter after subintimal passage of the guide wire was failed, we used Outback catheters. Successful recanalization was achieved intraluminally or subintimally in all cases. One perforation occurred during subintimal passage of the guide wire that was controlled by recanalization of another subintimal tract. There were no cases of distal thromboembolism or other complications.ConclusionA retrograde approach and using the Frontrunner and Outback catheters are safe and effective for successful revascularization of chronic total occlusion of femoropopliteal arteries. In particular, they are useful when the initial antegrade attempts at recanalization have failed.

Twelve months follow-up after retrograde recanalization of superficial femoral artery chronic total occlusion

“…In one case, due to severe calcifications, the distal access site was modified to tibial anterior artery puncture, with a good outcome and no severe complications. In our study the procedural success (88.2%) and 1-year patency rate (88.2%) were higher than average data reported [16]. Patients in our group were burdened with many comorbidities, and all of them were considered for a retrograde approach after failed antegrade crossing.…”

“…The structure of the lesion can determine the success of recanalization. A harder, calcified part in the proximal section and softer in the distal section may be more successful in transluminal intervention of CTOs by the retrograde approach [14–16]. …”

“…This maneuver could result in dislocation of the femoral sheath, prolongation of the procedure or deterioration of respiratory function [13, 14, 16]. Modifications to the method allow one position of the patient to be maintained and complications associated with the procedure to be reduced [14, 17–19].…”

Predictors of mortality and outcomes after retrograde endovascular angioplasty in patients with peripheral artery disease

“…Montero-Baker et al reported that the failure rate of antegrade recanalization can reach up to 20% in CTO lesions in lower limb arteries [8]. Difficulties in crossing the occlusion are related to the morphology of the plaque as CTOs are harder, more fibrous within the proximal cap, and with diffuse calcification [9–11]. For retrograde puncture, there are a few arteries that can be chosen: the distal segment of the SFA, PA, tibial artery, and pedal artery.…”

Comparative Assessment of Guidewire and Microcatheter vs a Crossing Device–Based Strategy to Traverse Infrainguinal Peripheral Artery Chronic Total Occlusions

“…More than 50% of procedures recorded in the XLPAD registry were performed for a CTO indication and, combined with the fact that CTO recanalization is associated with higher procedure failures and complications, the need for studies to optimize crossing strategies and outcomes becomes paramount. 12 To the best of our knowledge, no one has until now compared guidewire and microcatheter vs dedicated CTO devices for crossing infrainguinal peripheral artery CTOs. The main results of our study show that operators more often selected an initial wire-catheter strategy, although primary crossing success was significantly higher with an initial CTO device approach.…”