Retrograde transpopliteal recanalization of chronic superficial femoral artery occlusion after failed re-entry during antegrade subintimal angioplasty.
OBJECTIVE
To evaluate the acute success and clinical impact of retrograde transpopliteal access for subintimal recanalization of superficial femoral artery (SFA) and proximal popliteal artery (PA) occlusions after failed attempts to re-enter the true lumen in the antegrade femoral approach.


METHODS
From 2002 to 2007, 56 patients (43 men; mean age 68+/-9 years, range 43-87) with stable chronic peripheral artery disease (Rutherford category 2 to 5) were treated with antegrade subintimal angioplasty that could not be completed owing to re-entry failure. Mean occlusion length was 17+/-7 cm (range 4-32), including 13 TASC II A (23.2%), 10 TASC II B (17.8%), 16 TASC II C (28.5%), and 17 TASC II D (30.3%) lesions. After re-entry to the true lumen failed in the antegrade approach, including predilation of the false channel, all patients were turned to a prone position, and a 5-F or 6-F sheath was placed into the mid segment of the PA under fluoroscopic guidance. Retrograde wire passage was attempted with a 0.035-inch hydrophilic guidewire.


RESULTS
Fifty-five (98.2%) of 56 procedures were finished successfully with a residual stenosis of <30%; the 1 failure was due stent deformation within the occluded segment that could not be passed from either an antegrade or retrograde access. In all interventions, balloon angioplasty was performed; provisional stenting was done in 40 (71.4%). In 3 (5.3%) lesions, additional excimer laser atherectomy were performed. Six (10.7%) complications occurred, including 1 arteriovenous fistula from the PA to the popliteal vein and 1 sealing device induced PA occlusion. The mean ankle-brachial index increased from 0.44+/-0.26 to 0.86+/-0.23. The restenosis rate after 12 months was 54.9%.


CONCLUSIONS
Failed antegrade attempts to recanalize chronic total occlusions of the SFA and proximal PA can be salvaged using a retrograde popliteal access, with a low complication rate, as an alternative to using a re-entry device. However, durability of the intervention using current interventional tools is limited.
Department of Angiology, Herz-Zentrum Bad Krozingen, Germany. elias.noory@herzzentrum.de
Elias
E
Noory
Aljoscha
A
Rastan
Uwe
U
Schwarzwälder
Sebastian
S
Sixt
Ulrich
U
Beschorner
Karlheinz
K
Bürgelin
Franz-Josef
FJ
Neumann
Thomas
T
Zeller
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000628:therapy*; D017073:Atherectomy / Q000295:instrumentation; D003251:Constriction, Pathologic; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging; D006801:Humans; D054018:Lasers, Excimer; D008297:Male; D008875:Middle Aged; D011150:Popliteal Artery / Q000000981:diagnostic imaging; D016684:Prone Position; D011446:Prospective Studies; D015641:Radiography, Interventional; D012008:Recurrence; D012042:Registries; D012720:Severity of Illness Index; D015607:Stents; D016896:Treatment Outcome