title: Percutaneous bypass: subintimal recanalization of peripheral occlusive disease with IVUS guided luminal re-entry.
abstract: Angioplasty of chronic total occlusions (CTOs) has lower technical success rates with longer procedure times and poorer outcomes. Subintimal recanalization remains limited by the lack of controlled re-entry into the true lumen of the target vessel. We report our experience using a commercially available catheter-based system equipped with an intravascular ultrasound scanner to achieve controlled true lumen re-entry in patients with peripheral CTOs. In a 4-month period, 6 patients with lower extremity (LE) ischemia from CTOs were treated. Occluded segments were crossed subintimally, and controlled re-entry was secured using the CrossPoint TransAccess catheter. This 6.2 F dual-lumen catheter contains an integrated 64-element phased array intravascular ultrasound scanner enabling targeting of structures. Intravascular ultrasound-guided luminal re-entry was achieved by advancing a 24-gauge needle to a desired length and delivering a 0.014" guide wire into the target lumen. The occluded segments were balloon dilated and stented using self-expanding nitinol stents. Effective luminal re-entry and re-establishment of antegrade flow occurred in all 6 patients. Time to recanalization ranged from 5 to 10 minutes. All patients were free of ischemic symptoms at 1 to 5 month follow-up. There were no procedure-related complications. Our preliminary results demonstrate the feasibility of using this catheter system for subintimal recanalization with controlled re-entry in CTOs. This approach can improve the technical success rate, reduce the time of the procedure, and minimize potential complications.
authors.affiliation: Department of Cardiovascular-Interventional Radiology, Stanford University, Stanford, CA, USA.
authors.forename: Ramin R
authors.initials: RR
authors.lastname: Saketkhoo
authors.forename: Mahmood K
authors.initials: MK
authors.lastname: Razavi
authors.forename: Arash
authors.initials: A
authors.lastname: Padidar
authors.forename: Stephen T
authors.initials: ST
authors.lastname: Kee
authors.forename: Daniel Y
authors.initials: DY
authors.lastname: Sze
authors.forename: Michael D
authors.initials: MD
authors.lastname: Dake
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000379:methods*; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000628:therapy*; D002406:Catheterization, Peripheral / Q000295:instrumentation / Q000379:methods; D002908:Chronic Disease; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000628:therapy; D007866:Leg / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000000981:diagnostic imaging / Q000628:therapy; D011859:Radiography; D015607:Stents; D018084:Ultrasonography, Interventional