Long-term outcomes after re-entry device use for recanalization of common iliac artery chronic total occlusions

"Catheter Kissing" Technique to Recanalize Chronic Total Occlusions in Iliac Artery with Wire-Catheter Approach

BACKGROUND

To describe a technique in which 2 5-F curved catheters were used to facilitate the wire-catheter approach for recanalizing chronic total occlusions (CTOs) in the iliac arteries concurrently affecting the common iliac artery and external iliac artery.

METHODS

This was a single-center retrospective analysis involving endovascular recanalization of 17 iliac artery CTOs in 15 patients (mean age: 73.66 years; all men) between January 2019 and October 2022 using the subintimal arterial flossing with antegrade-retrograde intervention technique. With antegrade and retrograde guidewires in the subintimal spaces of CTOs, the location where the 2 guidewires seemed to overlap was identified as the rendezvous point. Although the 2 guidewires appeared to be in close proximity, there was no evidence that the bidirectional subintimal channels were connected. If several initial attempts failed, 2 5-F multipurpose catheters were introduced to the rendezvous point, followed by twisting, pulling, and pushing maneuvers until the tips of the catheters touched, indicating that the bidirectional subintimal channels were joined. A second wire rendezvous attempt was then employed to create a flossing-type guidewire. Outcome measurements included technical success, rendezvous points, complications, and procedure duration.

RESULTS

Among this cohort, 80.0% smoked and 66.7% had hypertension. In 11 limbs (64.7%), when initial wire rendezvous attempts failed, the "catheter kissing" technique was employed to successfully recanalize iliac artery CTOs, taking an average of 3.80 ± 1.64 min to complete the secondary wire rendezvous. The average length of CTOs was 111.06 ± 9.99 mm, with 7 (41.2%) and 8 (47.1%) cases exhibiting severe calcification and flush occlusion, respectively. The wire rendezvous point for all cases was in external iliac artery and the average time for successful secondary wire rendezvous was 3.80 ± 1.64 min. All patients were treated with iliac artery stents. No statistically significant difference was observed between the puncture sites of the common femoral artery and superficial femoral artery in relation to failure of the primary wire rendezvous (P = 0.644). No in-hospital deaths or complications were associated with the procedure, including iliac artery rupture, distal embolization, or access site complications.

CONCLUSIONS

In patients with extensive iliac artery CTOs, the "catheter kissing" technique may offer an effective and time-efficient recanalization approach, without requiring additional specialized devices. Importantly, the risk of complications remains unchanged even when employing a wire rendezvous in a challenging subintimal space.

Differences between Lower Extremity Arterial Occlusion vs. Stenosis and Predictors of Successful Endovascular Interventions

Background and Objectives: In patients with peripheral artery disease, there is insufficient understanding of characteristics that predict successful revascularization of the lower extremity (LE) chronic total occlusions (CTOs) and baseline differences in demographic, clinical, and angiographic characteristics in patients with LE CTO vs. non-CTO. We aim to explore these differences and predictors of successful revascularization among CTO patients. Materials and Methods: Two vascular centers enrolled LE-CTO patients who underwent endovascular revascularization. Data on demographics, clinical, angiographic, and interventional characteristics were collected. LE non-CTO arterial stenosis patients were compared. A total of 256 patients with LE revascularization procedures were studied; among them, 120 had CTOs and 136 had LE stenosis but no CTOs. Results: Aspirin use (Odds ratio, OR: 3.43; CI 1.32-8.88; p = 0.011) was a positive predictor whereas a history of malignancy (OR: 0.27; CI 0.09-0.80; p = 0.018) was a negative predictor of successful crossing in the CTO group. The CTO group had a higher history of myocardial infarction (29.2 vs. 18.3%, p = 0.05), end-stage renal disease (19.2 vs. 9.6%, p = 0.03), and chronic limb-threatening ischemia as the reason for revascularization (64.2 vs. 22.8%, p < 0.001). They were more likely to have advanced TransAtlantic Inter-Society Consensus (TASC) stages, multi-vessel revascularization procedures, longer lesions, and urgent treatment. Conclusions: The use of aspirin is a positive predictor whereas a history of malignancy is a negative predictor for successful crossing in CTO lesions. Additionally, LE-CTO patients have a higher incidence of comorbidities, which is expected given their higher disease burden. Successful endovascular re-vascularization can be associated with baseline clinical variables.

Use and effectiveness of Pioneer re-entry device for subintimal true lumen re-entry: single-centre data and a review of the literature

INTRODUCTION

During subintimal angioplasty (SIA), it is not always possible to re-enter the vessel lumen due to a variety of factors. Recanalization using hydrophilic wires and catheters alone, apart from its potential technical failure, is also limited by minimal control over the re-entry point. This is frequently well beyond the point of occlusion, thus often compromising important collaterals. In order to bypass the obstruction and attain controlled re-entry into the lumen of the diseased vessel, a re-entry device (RED) may be required. This paper assesses our centre's experience with the safety and efficacy of the Pioneer re-entry system and systematically reviews the pertinent literature.

METHOD

A single centre retrospective study of subintimal angioplasty involving the use of the Pioneer Plus intravascular guided reentry catheter was performed. Patient demographics including age, gender, risk factors, comorbidities clinical indication and complications were recorded. Lesion characteristics, including location and severity of calcification were also assessed. A systematic literature review of all reported studies where the Pioneer RED was used for iliac and lower limb revascularization was conducted by 2 of the authors using the PubMed (MEDLINE) and EMBASE databases.

RESULTS

The study comprised 30 cases. Technical success was 97%. A small, quickly resolved extravasation was the only device related complication. These results are in line with the systematic review which identified 16 studies using the Pioneer RED, reporting a technical success rate of 87.4-100% (median = 100%) and complication rate of 0-25.8% (median = 0%). However, due to heterogeneity in definitions of technical success, data was not pooled.

Safety and efficacy outcomes of the Pioneer Plus catheter in endovascular revascularization of lower extremity chronic total occlusions

OBJECTIVE

Our aim was to evaluate the efficacy and safety outcomes of the Pioneer Plus catheter (Philips, San Diego, Calif) and report the in-hospital and 30-day outcomes of lower extremity chronic total occlusion (CTO) interventions assisted by the Pioneer Plus catheter. In addition, we explored the factors associated with procedural success.

METHODS

We conducted a retrospective review of 135 consecutive procedures in 116 patients from July 2011 to September 2018 performed by eight operators with various levels of experience at a high-volume center where the Pioneer Plus catheter was used for lower extremity CTO. The patient demographics, preprocedural symptoms, preprocedural testing results, procedural setting, and angiography findings were abstracted. The outcomes were divided into device-related and procedure-related outcomes. Device-related efficacy outcome included procedural success. Device-related safety outcomes included device-related complications. Procedure-related outcomes included procedure-related complications, 30-day major adverse cardiovascular events, and 30-day major adverse limb events. We conducted univariate comparisons of the provider, patient, and procedural characteristics stratified by procedural success.

RESULTS

Procedural success was observed in 118 procedures overall (87.4%), and success rates ≤95.8% were observed for operators with an experience level of >25 devices deployed. No device-related complications, such as pseudoaneurysm formation, vessel perforation, or arteriovenous fistula formation, were observed. The Pioneer Plus catheter was mostly often used for CTO in the superficial femoral and popliteal arteries. Overall, the procedure-related complications included access site hematoma (5.2%), major bleeding (0.7%), pseudoaneurysm formation (0.7%), distal embolization (1.5%), and acute arterial thrombosis (1.5%). The 30-day major adverse limb events included index limb unplanned amputation (0.7%), index limb reintervention (4.4%), and index limb acute limb ischemia (0.7%) and occurred in 5.9% of the procedures. The only factor associated with procedural success was operator experience (P < .0001).

CONCLUSIONS

The results from the present study have shown that Pioneer Plus catheter use is safe and effective when used to cross lower extremity CTO. However, further investigation is needed to identify patient- and provider-level factors to optimize patient outcomes.

Effectiveness and long-term outcomes of different crossing strategies for the endovascular treatment of iliac artery chronic Total occlusions

Background

The iliac occlusive disease is usually treated with endovascular procedures in recent years. The effectiveness of different crossing approaches for these occlusions is not precisely known. We performed a retrospective study to explore the optimal crossing approach (antegrade versus retrograde) for iliac artery chronic total occlusions (CTOs) and to examine the long-term outcomes.

Materials and methods

We performed a study on 107 patients (116 iliac occlusive lesions, mean age 64.0 ± 11.1, 88 men) who underwent an iliac CTO endovascular intervention attempted with the use of both crossing strategies but were managed with one final crossing approach between August 2012 and August 2018. Baseline data, procedural characteristics, and outcomes were described. A Cox proportional hazard model and Kaplan-Meier method were developed to assess the differences in the two crossing approaches in terms of the 1-year and 5-year primary patency rates, target lesion revascularization (TLR) and major adverse limb events (MALEs).

Results

Common iliac artery (CIA) lesions were more likely to be crossed successfully in the retrograde direction (6.8% for antegrade vs. 20.9% for retrograde, p = 0.005), while lesions in the CIA/ external iliac artery (EIA) were more prone to be crossed successfully in the antegrade direction (58.9% for antegrade vs. 39.5% for retrograde, p = 0.016). There were no significant differences in the crossing approach for EIA lesions between the two groups. The two crossing approaches were associated with similar estimates of 1- and 5-year primary patency, TLR and MALE rates.

Conclusion

The antegrade approach was associated with a higher rate of successful crossing in CIA/EIA CTO lesions, while the CIA-only CTOs were more likely to be crossed successfully with the retrograde approach.

Efficacy of three-dimensional road mapping by fusion of computed tomography angiography and fluoroscopy in endovascular treatment of aorto-iliac chronic total occlusion

The efficacy of multimodality image fusion road-mapping technique for endovascular therapy has been reported recently. Our aim was to evaluate the efficacy of endovascular therapy (EVT) with three-dimensional (3D) road mapping by fusing computed tomography (CT) and angiographical volumetric data for aorto-iliac chronic total occlusion (CTO). We retrospectively analyzed 36 patients with aorto-iliac CTO from June 2017 to November 2019 and classified them into two groups: EVT using a CT fused 3D roadmap (CTf3D-RM; 3D group, n = 14) and standard EVT (standard group, n = 22). Primary endpoint was wiring time and secondary endpoints were procedural success rate, number of guidewires, procedure time, radiation dose, contrast medium dose, and complications. Wiring time was significantly shorter in the 3D group than the standard group (3D, 15.6 ± 10.23 min vs. standard, 44.6 ± 35.3 min; p = 0.0052). Both groups had high procedural success rates (3D, 100% vs. standard, 100%) and low complication rates (3D, 0.0% vs. standard, 9.1%; p = 0.51). There were significantly fewer guidewires in the 3D group than the standard group (3D, 2.78 ± 1.31 vs. standard, 4.36 ± 2.01; p = 0.0138). The 3D group trended towards shorter procedural time (3D, 78.8 ± 32.5 min vs. standard, 107.5 ± 52.5 min; p = 0.076), lower radiation dose (3D, 28.6 ± 18.9 Gycm² vs. standard, 48.9 ± 49.2 Gycm²; p = 0.15), and lower contrast medium dose (3D, 102.2 ± 30.6 vs. standard, 127.5 ± 51.3; p = 0.11) than the standard group. Therefore, we concluded that EVT with CTf3D-RM is effective for aorto-iliac CTO. This method may improve the quality of aorto-iliac CTO interventions.

The Use of Re-entry Devices in Aortoiliac Occlusive Disease

Endovascular approach is the first-choice treatment in patients suffering from aortoiliac occlusions. Nevertheless, standard endoluminal revascularization fails in treating occlusions in about 20% (1) of cases. Thus, subintimal revascularization can be a solution, but it fails in 25% (2) of cases as well. In the last decades, different devices have been created, in order to ease the cross back into the true lumen, when standard subintimal revascularization does not work or risks to occlude important collateral vessels. Herein, we revise the currently available re-entry devices and their application in the aortoiliac occlusive pathology.

Native Microchannel Recanalization with Orbital Atherectomy as a Viable Alternative to Failed Standard Recanalization of TASC II D Aortoiliac Occlusive Disease

BACKGROUND

Endovascular treatment of Trans-Atlantic Inter-Society Consensus (TASC) II D aortoiliac lesions is now an accepted form of revascularization. We sought to demonstrate that native microchannel recanalization and orbital atherectomy is a successful recanalization method of TASC II D aortoiliac lesions refractory to standard recanalization techniques.

METHODS

Four consecutive patients from 2016 to 2018 with symptomatic TASC II D aortoiliac occlusive disease prohibitive for open bypass and failed traditional prodding guidewire or device recanalization technique were identified and underwent advanced native microchannel selection and subsequent orbital atherectomy (Cardiovascular Systems, Inc, St Paul, MN). Native microchannels of the calcified lesions were probed and traversed with a 0.014″ wire. The atherectomy crown was tracked over the wire, and orbital atherectomy was initiated with a 1.25 mm crown starting at the lowest revolution and continued until the microchannel is sufficiently large to track a 1.2 mm-balloon for angioplasty. Serial microchannel angioplasty with exchange for stiffer and/or larger profile wires and balloons was achieved until a covered stent could be safely deployed across the target lesion. The kissing stent technique was then used to recreate the aortic bifurcation. A ViperSlide lubricant solution was used in all cases per indication for use. Patients were all heparinized to maintain an activated clotting time of 250. Lesion characteristics, survival, limb salvage, patency, and change in clinical symptoms were also analyzed.

RESULTS

All 4 patients underwent successful native microchannel recanalization and orbital atherectomy of the common iliac artery (CIA). There were no intraoperative ruptures, embolizations, or dissections. All 4 patients presented with unilateral CIA occlusion with contralateral CIA stenosis. The average occlusion lesion length of the CIA was 6.0 cm. The average contralateral stenosis length was 2.3 cm. The kissing stent technique was used in all patients for reconstruction of the aortic bifurcation. At 30 days, all patients had improvement in pain and primary patency of 100%. Long-term follow-up at 21.6 months noted continued improvement in symptoms and primary patency of 75%. The fourth patient died at 4 months from lung cancer with occluded iliac stents by imaging at that time.

CONCLUSIONS

Native microchannel recanalization with subsequent orbital atherectomy is an option in high-risk patients with TASC II D aortoiliac disease who have failed traditional recanalization techniques. Further work in proper patient selection and safe utilization of atherectomy devices in the CIA is needed.

Use, Safety and Effectiveness of Subintimal Angioplasty and Re-Entry Devices for the Treatment of Iliac Artery Chronic Total Occlusions: A Systematic Review of 30 Studies and 1112 Lesions

BACKGROUND

Management of iliac artery occlusive disease has changed dramatically over the past few decades. Secondary to advancement in endovascular technologies and techniques, percutaneous interventions have gradually replaced open surgical approaches even for the most difficult cases. In difficult to cross chronic total occlusions (CTO) of the iliac artery, subintimal angioplasty (SIA) with or without the use of re-entry devices (RED) offers a valuable alternative to intra-luminal crossing.

OBJECTIVE

To systematically review the literature for studies reporting procedural or short- and long-term clinical outcomes after the use of SIA, with or without RED use for iliac CTOs.

METHODS

PRISMA guidelines were followed. Literature search (PubMed, Cochrane CENTRAL and EMBASE) and data extraction were performed by two independent researchers. Quantitative synthesis of the reported outcomes was applied when possible.

RESULTS

Thirty studies met the inclusion criteria and were selected as eligible for this systematic review, with a total of 1002 patients (61.3% males) and 1112 lesions treated with SIA. RED were used in 21.9% of the lesions. Critical limb ischemia was the indication in 51.4%. The overall procedural success rates were 85.8% for SIA and 88.5% for RED. The complication rate ranged from 0 to 10% among different series, but overall it was similar among the two groups (6.9% in the RED group and 6.7% among the SIA group). One year primary patency rates were around 60% in the RED. In the SIA only arm, there was a large heterogeneity, with patency rates ranging from 51.7% to 96.8%.

CONCLUSION

SIA with or without RED use is a safe and effective treatment for the treatment of iliac artery CTOs. Future studies are needed to delineate whether intraluminal crossing or SIA is more effective for endovascular treatment of iliac CTOs.

Acute and Midterm Outcomes of Antegrade vs Retrograde Crossing Strategies for Endovascular Treatment of Iliac Artery Chronic Total Occlusions

Purpose: To examine whether an antegrade or retrograde crossing strategy for treatment of iliac artery chronic total occlusions (CTOs) is associated with differences in procedural or midterm outcomes. Materials and Methods: A dual-center retrospective cohort study was conducted in 168 patients (mean age 66.4±10.6 years; 116 men) treated for CTOs in 110 common iliac arteries (CIA), 52 external iliac arteries (EIA), and 26 combined CIA/EIAs. Logistic regression models were developed to determine the association between crossing strategy and procedural complications, 1- and 3-year target lesion revascularization (TLR), and major adverse limb events (MALE). Results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: An initial antegrade strategy was more common for EIA CTOs (p<0.005), and an initial retrograde strategy was more often used in CIA (p<0.005) and combined CIA/EIA (p<0.005) CTOs. Crossover to an alternate approach was required in 27.6% of initial antegrade attempts and 9.6% of initial retrograde attempts. EIA CTOs were the most likely lesions to be treated successfully with the initial attempt (either strategy). In all, 123 (65.4%) lesions were successfully crossed with a final retrograde approach and 65 with a final antegrade approach. Overall target lesion success was high for both groups (95.1% vs 93.2%, p=0.456). Lesions treated with a final retrograde approach were shorter (75.3±34.9 vs 87.6±31.3 mm, p=0.005) and were more likely to be treated with a reentry device (34.2% vs 9.2%, p<0.001) and with balloon-expandable stents (39.2% vs 17.7%, p=0.005). The final antegrade approach was associated with a lower risk of target lesion complications (OR 0.07, 95% CI 0.01 to 0.81, p=0.034). The two crossing approaches were associated with similar estimates of 1- and 3-year TLR and MALE. Conclusion: A final antegrade approach was associated with lower rates for complications but the 2 approaches were similar in terms of lesion success, TLR, and MALE. The EIA CTOs were more likely to be treated with an antegrade approach and more likely to be crossed successfully with the initial approach irrespective of the crossing direction.