Recanalization of chronic occlusions of the superficial femoral artery using the outback™ re‐entry catheter: A single centre experience

Purpose : To report our experience with a catheter system (The Outback? catheter) designed to allow fluoroscopically controlled re‐entry after subintimal guide wire passage during recanalization of chronically occluded femoro‐popliteal arteries. Methods : Between March 2007 and August 2008, 65 legs in 61 patients (60% male, mean age 73 (49–98 years) with chronic occlusion of the SFA and proximal popliteal artery were treated. Clinical presentation was severe intermittent claudication (Rutherford category 3, 59%), rest pain (Rutherford category 4, 16%), and minor ulcerations (Rutherford category 5, 25%). In all cases, the true lumen could not be entered by using standard antegrade catheter and guide wire techniques. Results : Median lesion length was 200 ± 102 mm. Recanalization of the arterial occlusion was successful in 57 of 65 treated lesions (88%). One patient died of myocardial infarction after delayed femoral bleeding possibly due to extensive recanalization attempts. There were no further procedure‐related complications. Conclusion : Use of the Outback? re‐entry catheter system is a valuable option for interventional therapy of chronically occluded femoro‐popliteal arteries following failed standard antegrade recanalization attempt. © 2009 Wiley‐Liss, Inc.     

Retrograde approach to recanalization of complex tibial disease

A significant proportion (～20%) of patients with complex tibial artery occlusions cannot be treated using a conventional antegrade approach. We report our experience using the retrograde approach for the treatment of complex tibial artery occlusive disease using retrograde pedal/tibial access in 13 limbs from 12 patients. Retrograde pedal/tibial access was achieved in all cases (facilitated by surgical cutdown in one case), and procedural success was achieved in 11 of 13 limbs (85%). Based on this experience, a discussion of clinical and technical aspects of the retrograde pedal/tibial approach is provided, and a new classification for tibial artery occlusive disease is proposed. © 2011 Wiley‐Liss, Inc.     

Succesful antegrade subintimal bypass restenting of in‐stent chronic total occlusion

Coronary chronic total occlusions (CTOs) are known to cause significant patient morbidity. Over the past several years, the techniques and devices for treating these CTOs have advanced tremendously. The interventional management of CTOs within previously placed coronary stents, however, remains challenging. Here, we present a case of an in‐stent restenosis of the right coronary artery CTO bypassed using a controlled subintimal dissection re‐entry technique via antegrade approach creating side‐by‐side stents. © 2015 Wiley Periodicals, Inc.     

Initial experience with a dedicated coronary re-entry device for revascularization of chronic total occlusions

Objective : The aim of this registry was to evaluate a new device designed to facilitate antegrade guidewire re‐entry into the true lumen of a chronic total coronary occlusion (CTO) from the adjacent subintimal space. Background : Successful recanalization of CTOs results in clinical improvement in appropriately selected patients. CTO intervention is time‐ and resource‐consuming, and a simplified approach enabling antegrade guidewire re‐entry into the distal true lumen might improve success. Methods : Patients with CTO and ischemia were entered into a prospective registry regardless of lesion characteristics. If wire manipulation resulted in subintimal wire entrapment, a new re‐entry tool (a 2.5‐mm flat subintimal balloon with two exit ports offset by 180°) was used as a platform to attempt guidewire penetration into the distal true lumen. The primary endpoint assessed was successful device‐guided re‐entry. Standard techniques were then utilized to open the CTO. Results : In 40 consecutive CTO lesions attempted, 19 resulted in subintimal wire entrapment (mean occlusion length 44 mm). Sixteen of these 19 were successfully crossed with an antegrade guidewire into the distal true lumen using the new device (84%). One patient with unsuccessful re‐entry was subsequently recanalized with a retrograde technique. All crossed lesions were stented (17/17), resulting in TIMI 3 flow without major complications. Two cases were unsuccessful. One patient had a grade I coronary perforation requiring no treatment. Conclusions : A new device to recanalize CTOs complicated by subintimal wire entrapment can be used successfully by experienced operators. Further study of this coronary re‐entry device is ongoing. © 2011 Wiley Periodicals, Inc.     

Combined radial‐tibial access strategy and radial‐tibial reverse CART in a patient with aortobifemoral graft and complex superficial femoral artery occlusion

We present the case of a patient with a history of aortobifemoral grafting who presented with left lower extremity ischemic rest pain. Aortofemoral angiography was performed through a left radial access and showed a long, calcified total occlusion of the left superficial femoral artery (SFA) and a subtotal popliteal occlusion. The popliteal artery and SFA were crossed retrogradely through a 4‐Fr anterior tibial access; the retrograde devices went subintimally and did not reenter at the common femoral level. Subsequently, the radial access was used for antegrade subintimal crossing and dilatation of the SFA, which allowed reentry of the retrograde devices (radial‐tibial reverse controlled antegrade‐retrograde tracking [CART]). The SFA was then successfully treated retrogradely with orbital atherectomy and drug‐coated balloon angioplasty, through a 4‐Fr equivalent tibial sheath. © 2017 Wiley Periodicals, Inc.     

One‐year outcomes after successful chronic total occlusion percutaneous coronary intervention: The impact of dissection re‐entry techniques

We aimed to determine clinical outcomes 1 year after successful chronic total occlusion (CTO) PCI and, in particular, whether use of dissection and re‐entry strategies affects clinical outcomes. Hybrid approaches have increased the procedural success of CTO percutaneous coronary intervention (PCI) but longer‐term outcomes are unknown, particularly in relation to dissection and re‐entry techniques. Data were collected for consecutive CTO PCIs performed by hybrid‐trained operators from 7 United Kingdom (UK) centres between 2012 and 2014. The primary endpoint (death, myocardial infarction, unplanned target vessel revascularization) was measured at 12 months along with angina status. One‐year follow up data were available for 96% of successful cases (n = 805). In total, 85% of patients had a CCS angina class of 2–4 prior to CTO PCI. Final successful procedural strategy was antegrade wire escalation 48%; antegrade dissection and re‐entry (ADR) 21%; retrograde wire escalation 5%; retrograde dissection and re‐entry (RDR) 26%. Overall, 47% of CTOs were recanalized using dissection and re‐entry strategies. During a mean follow up of 11.5 ± 3.8 months, the primary endpoint occurred in 8.6% (n = 69) of patients (10.3% (n = 39/375) in DART group and 7.0% (n = 30/430) in wire‐based cases). The majority of patients (88%) had no or minimal angina (CCS class 0 or 1). ADR and RDR were used more frequently in more complex cases with greater disease burden, however, the only independent predictor of the primary endpoint was lesion length. CTO PCI in complex lesions using the hybrid approach is safe, effective and has a low one‐year adverse event rate. The method used to recanalize arteries was not associated with adverse outcomes. © 2017 Wiley Periodicals, Inc.     

Rotational atherectomy in the subadventitial space to allow safe and successful chronic total occlusion recanalization: Pushing the limit further

Dissection and re‐entry (DR) techniques have played a key role in the increase of success rates of chronic total occlusion (CTO) recanalization. DR usually allows wiring complex occlusions, even in case of important calcification. In extreme cases, such as in balloon failure‐to‐cross, rotational atherectomy (RA) might be decisive. However, according to experts' recommendations, RA should not be performed in dissection planes because of the high risk of perforation and further extending the dissection, so that its use after DR might be limited. Here, we describe a case of successful right coronary artery CTO recanalization in which, after failure of several antegrade and retrograde techniques, RA was safely performed antegradely in the subadventitial space, thus eventually enabling reverse controlled antegrade and retrograde subintimal tracking (CART). Although the feasibility of RA in CTO percutaneous coronary intervention had already been suggested, this case reports on the novel use of RA to allow further manipulation of the subadventitial space (reverse CART) prior to successful recanalization. © 2017 Wiley Periodicals, Inc.     

Usefulness of the Corsair microcatheter for treatment of complex chronic total occlusion

Percutaneous coronary intervention (PCI) for the treatment of chronic total occlusion (CTO) is one of the most technically challenging areas of interventional cardiology. When CTO is combined with angulation and tortuosity of the coronary artery, the technical complexity of PCI for CTO is magnified. In this report, we describe a case of successful revascularization of a CTO lesion in the complex circumflex anatomy using a novel microcatheter (the Corsair catheter) along with an antegrade approach to facilitate guidewire passage through a proximal steep angulation and to cross the circumflex CTO lesion that was unresponsive with conventional microcatheters.     

A successful retrograde re‐entry at aorta using the outback LTD catheter for a bilateral common iliac artery occlusion

The Outback LTD re‐entry catheter system has become a valuable tool for peripheral intervention and it has been widely used for variable peripheral chronic total occlusion (CTO). However, its use in the setting of the aorta was restricted because of concerns of bleeding risks resulting from re‐entry puncture or ballooning. This report presents a case of successful re‐entry using the Outback LTD Re‐Entry Catheter (Cordis, Bridgewater, New Jersy) at the aorta in a patient with bilateral common iliac artery occlusion. © 2013 Wiley Periodicals, Inc.     

Retrograde Recanalization of an occluded posterior tibial artery by using a posterior tibial cutdown: Two case reports

Recanalization of two occluded posterior tibial arteries was successfully achieved by utilizing a retrograde approach via a posterior tibial artery cutdown at the level of the ankle. Both cases were previously unsuccessfully attempted by using an antegrade approach. Thus, the choice of access vessel (arterial entry site) becomes a crucial determinant of angioplasty success.     

Intracoronary snaring of the retrograde guidewire: How to overcome extreme takeoff angles in chronic total occlusion percutaneous coronary intervention

Extreme angulation of coronary artery takeoff represents a challenge for wiring and device advancement in percutaneous coronary intervention (PCI). This anatomic feature is particularly adverse in cases of chronic total occlusion (CTO) of the ostial‐proximal segment of the target vessel. In this setting, the retrograde approach can help getting access to the occlusion. However, difficulties might arise at the critical step of wire externalization, due to the need to overcome the extreme ostial angle. Here, we describe a case of successful CTO PCI of the proximal circumflex artery, which presented an extreme angle at its takeoff. Due to inability to perform antegrade wiring of the occlusion, the retrograde approach was undertaken via epicardial collaterals from the right coronary artery. Since conventional attempts at re‐entering the antegrade guiding catheter failed due to the aforementioned extreme angle, the retrograde wire was snared in the mid left anterior descending artery, and externalization was performed. This case demonstrates the usefulness of coronary snares in the CTO operator's toolkit and shows how such devices can be used to safely and successfully complete challenging retrograde procedures.     

The “double stingray technique” for recanalizing chronic total occlusions with bifurcation at the distal cap

Antegrade dissection re‐entry is often discouraged for chronic total occlusions (CTOs) with a bifurcation at the distal cap due to risk of side branch occlusion that can lead to periprocedural myocardial infarction and incomplete revascularization. Antegrade dissection re‐entry, however, is often needed, especially in complex cases. We present the novel “double Stingray technique” for CTOs involving bifurcations, in which the Stingray system is used twice for re‐entry into both vessel branches, followed by two‐stent bifurcation stenting to maintain the patency of both branches.     

Improvements in Artery Occlusion by Low‐Density Lipoprotein Apheresis in a Patient with Peripheral Arterial Disease

Abstract: Peripheral arterial disease (PAD; arteriosclerosis obliterans) shows ischemic symptoms along the peripheral arteries due to reduced blood flow, and the number of patients with PAD is increasing. Several papers have reported on the clinical effect of low‐density lipoprotein apheresis (LDL‐A) on PAD, but there has been no report so far on the improvement of total peripheral artery stenosis by LDL‐A. We report on the clinical course of a female PAD patient with intractable decubitus in her heel due to the complete occlusion of anterior tibial artery who was treated by a series of LDL‐A sessions. The complete occlusion of the anterior tibial artery improved as seen on angiography, and the decubitus in her heel also markedly improved after LDL‐A therapy. This report supports the clinical benefit of LDL‐A for the treatment of PAD.     

Medial-to-lateral plantar loop technique for retrograde transcollateral recanalization of the lateral plantar artery in patients with type 3 plantar arch

A 89-year-old male presented with severe untreatable pain and ischemic non-healing ulcer in the left forefoot. The pre-procedural angiograms showed multiple stenosis of the superficial femoral and popliteal arteries, occlusion of anterior tibial artery, tibio-peroneal trunk (TTP) and distal posterior tibial artery (PTA), stenosis of the peroneal artery, and the patency of the medial plantar artery (MPA) as a single pedal artery, with very poor perfusion of the lateral aspect of the forefoot. The TTP and PTA were recanalized, and balloon angioplasty of superficial femoral artery and popliteal artery and peroneal artery was carried out. After unsuccessful antegrade attempts, the lateral plantar artery (LPA) was retrogradely recanalized performing the medial-to-lateral plantar loop, navigating from the deep branch of MPA to the plantar arch and reentering back in the common plantar artery through the LPA. Balloon angioplasty of LPA was performed though the retrograde and antegrade route. When the MPA is the single pedal artery, and the antegrade recanalization of the dorsalis pedis artery (DPA) and the LPA is not possible, the medial-to-lateral plantar loop is a feasible technique to recanalize the LPA retrogradely through the plantar arch.     

Retrograde crossing through the pedal arch for totally occluded tibial artery

Critical limb ischemia is characterized by atherosclerotic disorder of the crural arteries. The occlusion of darsalis pedis and paramalleolar posterior tibial arteries is a rare atherosclerotic pattern in the crural arteries. We present a successful case of retrograde posterior tibial artery crossing through the pedal arch after antegrade recanalization of occluded anterior tibial and dorsalis pedis arteries, leading to the achievement of complete infrapopliteal recanalization and wound healing.     

Chronische Koronarverschlüsse

Chronic occlusion of coronary arteries also known as chronic total occlusions (CTO) are found in approximately 20?% of patients undergoing percutaneous coronary interventions (PCI) and in approximately 50?% of patients after coronary artery bypass grafts (CABG). As a result of technical advancements in retrograde recanalization techniques specialized centers can now achieve success rates of over 85?%, regardless of the CTO anatomy. Given the complexity of retrograde CTO techniques, a consensus paper issued by the Euro CTO Club requires interventional cardiologists to have sufficient experience in antegrade approaches (>300 antegrade CTO cases and >50 per year) with an additional training program (25 retrograde cases each as first and second operating surgeon) before becoming a qualified independent retrograde surgeon. The increased investment in time and technical resources can only be justified if the patient has a clear clinical benefit. This technical advancement and the progressively clearer evidence that complete revascularization can be achieved in patients with multivessel coronary artery disease have attracted growing interest in recent years from interventional cardiologists in the recanalization of CTO.     

Antegrade Techniques for Chronic Total Occlusions

By convention, a total obstruction of the coronary artery with no flow at the occluded segment that has been present for at least 3 months is termed as chronic total occlusion or CTO. This is to be distinguished from a sudden occlusion of the coro-nary artery lumen by a thrombus during an acute myocardial infarction. Percutaneous coronary intervention (PCI) of CTO is increasingly being performed by interventional cardiologists with improved success rates. In this article, the focus will be on antegrade techniques that will assist the operator to maximise the success rates and to minimise the complications.     

Retrograde balloon hemostasis

Despite improvements in current devices and techniques for complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI), procedural complications, including coronary perforation, still occur and could be life-threatening. A patient with a history of multivessel coronary artery disease and a CTO of the right coronary artery (RCA) underwent successful retrograde crossing of an RCA CTO. After wiring the CTO body and lesion dilatation, a drug-eluting stent was implanted in the distal RCA toward the posterior descending artery. A large Ellis type III perforation occurred at the distal edge of the stent. Septal crossing with a balloon and tamponade of the perforation site through the retrograde collaterals followed, as the RCA was not suitable to accommodate easily both the covered stent and the balloon simultaneously. This case report presents a novel approach the “septal retrograde ping-pong” technique, which demonstrates successful treatment of coronary perforations by utilizing a retrograde approach through a septal collateral. This technique proves to be effective in situations where the conventional antegrade balloon or covered stent delivery methods are not feasible or unsuccessful. This innovative approach offers a promising alternative for managing challenging cases of coronary perforations, providing new insights and potential solutions for interventional cardiologists.     

Retrograde posterior tibial artery access for below-the-knee percutaneous revascularization by means of sheathless approach and double wire technique

Arterial revascularization by means of percutaneous transluminal angioplasty (PTA) is a mainstay in the management of patients with peripheral artery disease and critical limb ischemia (CLI). While cross-over access from the contralateral femoral artery or antegrade access from the ipsilateral femoral artery are most commonly used when approaching subjects with CLI, PTA may occasionally fail when performed from these routes. We hereby report a patient in whom we performed retrograde arterial access through the posterior tibial artery, thus enabling recanalization of a challenging below-the-knee chronic total occlusion. Technical points pertinent to this case are clearly illustrated, including the sheathless approach and the use of a double wire strategy, one advanced ante-gradient and the other concomitantly advanced retro-gradient..     

Long‐term outcomes of intraoperative pulmonary artery stent placement for congenital heart disease

We report a novel technique for performing retrograde interventions on a coronary chronic total occlusion through an ipsilateral collateral. Two guiding catheters are used to engage the target coronary artery, one to advance to the retrograde guidewire and the other to externalize the retrograde guidewire and antegrade wiring. Engagement of the target coronary artery is alternating between the antegrade and the retrograde guide catheter in a “ping‐pong” fashion, enabling lesion crossing and equipment delivery. © 2011 Wiley‐Liss, Inc.