Korean J Radiol.  2012 Aug;13(4):467-475. 10.3348/kjr.2012.13.4.467.

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

• Lee HJ
• Park SW
• Chang IS
• Jeon HJ
• Park JH

• KMID: 1383859
• DOI: http://doi.org/10.3348/kjr.2012.13.4.467

Abstract

OBJECTIVE
To 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 METHODS
Twenty-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.
RESULTS
In 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.
CONCLUSION
A 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.

Keyword

Intervention; Percutaneous transluminal angioplasty; Angiography; Fluoroscopy

MeSH Terms

Aged
Aged, 80 and over
Angiography
*Angioplasty, Balloon
Arterial Occlusive Diseases/*radiography/*surgery
*Catheterization, Peripheral
Female
*Femoral Artery
Humans
Male
Middle Aged
*Popliteal Artery
Prospective Studies
*Stents
Treatment Outcome

Figure

• 

  Fig. 1 64-year-old man with severe claudication (Fontaine classification IIb) of right leg. A-C. Patient had chronic total occlusion of about 20 cm of right superficial femoral artery on angiogram. Successful recanalization with Frontrunner XP chronic total occlusion catheter was achieved into reconstituted artery (arrow). D. Primary stent placement with self-expandable nitinol stents was performed.

• 

  Fig. 2 73-year-old man with severe claudication (Fontaine classification IIb) of both legs. A. Patient had chronic total occlusion of about 8 cm of left superficial femoral artery on angiogram (arrow). B. Reentry of 0.035 inch hydrophilic guide wire into true lumen could not be achieved. C, D. Under ultrasound guidance, popliteal arterial puncture was performed and chronic total occlusion lesion was crossed subinitmally in retrograde fashion. Anterograde snare was used to maneuver wire into sheath to facilitate subsequent procedures in anterograde manner. E. Thereafter, balloon angioplasty followed by stent placement was performed in femoropopliteal arteries and hemostasis in popliteal artery was established by manual compression.

• 

  Fig. 3 81-year-old-woman with severe claudication (Fontaine classification IIb) of left superficial femoral artery (SFA). A. Patient had chronic total occlusion of about 17 cm in left SFA on angiogram. B. Fluoroscopic images show Outback catheter and its needle deployed (double arrows) with free passage of guide wire into true lumen of reconstituted artery. L configuration at catheter nosecone is noted (arrow). C. Final angiogram demonstrates that patency was restored following stent placement.

• 

  Fig. 4 71-year-old-man with resting pain (Fontaine classification III) in left foot. A. CT angiography shows chronic total occlusion of left superficial femoral artery (SFA). B. Initial attempt with conventional techniques using hydrophilic guide wire and angiographic catheter created reentry at P2 segment of popliteal artery (arrow). Angiogram after subintimal angioplasty showed suboptimal results (thin arrows). C. Outback catheter was used to create new reentry site at more proximal artery to P2 segment of popliteal artery to allow stent to be placed. D. Self-expandable nitinol stent was placed at distal SFA including new reentry site. E, F. Final angiogram demonstrates that patency was restored following stent placement.

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