Korean Circ J.  2017 Jan;47(1):89-96. 10.4070/kcj.2016.0310.

Procedural and Early Outcomes of Two Re-entry Devices for Subintimal Recanalization of Aortoiliac and Femoropopliteal Chronic Total Occlusions

• Vuruskan E
• Saracoglu

• KMID: 2365287
• DOI: http://doi.org/10.4070/kcj.2016.0310

Abstract

BACKGROUND AND OBJECTIVES
Subintimal angioplasty is a common treatment choice for chronic total occlusions (CTO) in the iliac and femoropopliteal arteries. This article describes the technical aspects and early outcomes of two different re-entry devices and comparison with manual re-entry technique.
SUBJECTS AND METHODS
A retrospective review of 61 patients (re-entry group) treated with Outback or Pioneer Plus catheters was carried out. A matched cohort of patients (n=62) who underwent lower extremity interventions without the use of re-entry devices (manual re-entry group) were also analyzed (overall 123 patients were analyzed). Procedural success, procedural durations, patency estimates, ankle-brachial indices, and complications were analyzed.
RESULTS
Sixty-one patients underwent Outback or Pioneer Plus guided subintimal recanalization. After the procedure, ankle-brachial indices significantly increased in all patients during follow-up. Primary patency for the entire cohort was 83% in the first month. When the re-entry device group was compared with manual re-entry group, no difference was found with respect to success, complication, and patencies between the two groups during follow-up. However, procedure duration and the amount of contrast agent used was significantly decreased in re-entry groups (p<0.001). Also, re-entry time was significantly decreased in Pioneer plus group according to Outback group (p<0.001)
CONCLUSION
Recanalization of CTO using re-entry devices for aortoiliac or femoropopliteal arteries is safe and effective. These devices shorten the procedure time, the re-entry time, reduce radiation risk, and reduce the amount of contrast agent employed.

Keyword

Peripheral arterial disease; Angioplasty

MeSH Terms

Angioplasty
Ankle Brachial Index
Arteries
Catheters
Cohort Studies
Follow-Up Studies
Humans
Lower Extremity
Peripheral Arterial Disease
Retrospective Studies

Figure

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  Fig. 1 Reentry systems. (A) Outback catheter, (B) Pioneer Plus catheter, (C) demonstration of TL and FL via IVUS images are obtained by the transducer integrated to Pioneer plus reentry catheter. (D) Calculation of re-entry distance via fluoroscopy. TL: true lumen, FL: false lumen, IVUS: intravascular ultrasound.

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  Fig. 2 Case example of RCIA stenosis and LCIA flush occlusion before (A) and after (B) the procedure with an Outback catheter. Abd Aorta: abdominal aorta, RCIA: right common iliac artery, CTO: chronic total occlusion, LCIA: left common iliac artery.

Reference

1. Patel MR, Conte MS, Cutlip DE, et al. Consensus definitions for evaluation of patients with lower extremity peripheral artery disease: The Peripheral Academic Research Consortium (PARC). J Am Coll Cardiol. 2015; 65:931–941.

2. Kjellgren O, Feld S, Loyd D, et al. Successful treatment of chronic total peripheral occlusions that failed with conventional techniques using the stiff back-end of the Glidewire. Cathet Cardiovasc Diagn. 1995; 36:360–363.

3. European Stroke Organisationtion. Tendera M, Aboyans V, et al. ESC guidelines on the diagnosis and treatment of peripheral artery diseases. Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the task force on the diagnosis and treatment of peripheral artery diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011; 32:2851–2906.

4. Jaff MR, White CJ, Hiatt WR, et al. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: a supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II). Ann Vasc Dis. 2015; 8:343–357.

5. Arslan S, Yuksel IO, Koklu E, et al. Clinical and morphological features of patients who underwent endovascular interventions for lower extremity arterial occlusive disease. Postepy Kardiol Interwencyjnej. 2015; 11:114–118.

6. Bolia A, Miles KA, Brennan J, Bell PR. Percutaneous transluminal angioplasty of occlusions of the femoral and popliteal arteries by subintimal dissection. Cardiovasc Intervent Radiol. 1990; 13:357–363.

7. Capek P, McLean GK, Berkowitz HD. Femoropopliteal angioplasty: factors influencing long-term success. Circulation. 1991; 83:2 Suppl. I70–I80.

8. Jacobs DL, Motaganahalli RL, Cox DE, Wittgen CM, Peterson GJ. True lumen devices facilitate subintimal angioplasty and stenting of total chronic occlusions: Initial report. J Vasc Surg. 2006; 43:1291–1296.

9. Patel SD, Biasi L, Paraskevopoulos I, et al. Comparison of angioplasty and bypass surgery for critical limb ischaemia in patients with infrapopliteal peripheral artery disease. Br J Surg. 2016; [Epub ahead of print].

10. Spanos K, Kouvelos G, Karathanos C, Xhepa S, Giannoukas A, Matsagkas M. New devices to cross chronic total occlusion in critical limb ischemia. J Cardiovasc Surg (Torino). 2016; [Epub ahead of print].

11. Hamur H, Onk OA, Vuruskan E, et al. Determinants of Chronic Total Occlusion in Patients With Peripheral Arterial Occlusive Disease. Angiology. 2016; [Epub ahead of print].

12. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007; 45:Suppl S. S5–S67.

13. Tønnesen KH, Sager P, Karle A, Henriksen L, Jørgensen B. Percutaneous transluminal angioplasty of the superficial femoral artery by retrograde catheterization via the popliteal artery. Cardiovasc Intervent Radiol. 1988; 11:127–131.

14. London NJ, Srinivasan R, Naylor AR, et al. Subintimal angioplasty of femoropopliteal artery occlusions: The long-term results. Eur J Vasc Surg. 1994; 8:148–155.

15. Laxdal E, Jenssen GL, Pedersen G, Aune S. Subintimal angioplasty as a treatment of femoropopliteal artery occlusions. Eur J Vasc Endovasc Surg. 2003; 25:578–582.

16. Yilmaz S, Sindel T, Lüleci E. Bilateral transpopliteal approach for treatment of complex SFA and iliac occlusions. Eur Radiol. 2002; 12:911–914.

17. Villas PA, Cohen G, Goyal A, Putnam SG 3rd, Ball D. The merits of percutaneous transluminal angioplasty of a superficial femoral artery stenosis via a retrograde popliteal artery approach. J Vasc Interv Radiol. 1999; 10:325–328.

18. Al-Ameri H, Shin V, Mayeda GS, et al. Peripheral chronic occlusions treated with subintimal angioplasty and a true lumen re-entry device. J Invasive Cardiol. 2009; 21:468–472.

19. Landis GS, Faries PL. New techniques and developments to treat long infrainguinal arterial occlusions: Use of reentry devices, subintimal angioplasty, and endografts. Perspect Vasc Surg Endovasc Ther. 2007; 19:285–290.

20. Jacobs DL, Cox DE, Motaganahalli R. Crossing chronic total occlusions of the iliac and femoral-popliteal vessels and the use of true lumen reentry devices. Perspect Vasc Surg Endovasc Ther. 2006; 18:31–37.

21. Araki M, Hirano K, Nakano M, et al. Two-year outcome of the self-expandable stent for chronic total occlusion of the iliac artery. Cardiovasc Interv Ther. 2014; 29:40–46.