Targeted tibio-peroneal re-entry during subintimal revascularization using the Outback® catheter

BACKGROUND

Re-entry devices are used regularly in subintimal recanalization of chronic occlusions of the iliac and femoro-popliteal arteries and significantly contribute to the high success rate of these interventions. However, the use in tibio-peroneal arteries has only been described in few cases so far. The present work is a retrospective evaluation of the Outback® re-entry device for gaining targeted true lumen access at the level of the tibio-peroneal arteries.

METHODS

From 9/2017 until 10/2020 the Outback® catheter was used in case of failed spontaneous re-entry at the level of the tibio-peroneal arteries in 14 patients either instead of the usual retrograde approach via a pedal/distal-crural access (n = 11) or in combination with it (n = 3). Baseline demographic and clinical data, morphologic characteristics of the occlusions, procedural succedss, as well as the Society of Vascular Surgery (SVS) runoff score before and after revascularization were documented.

RESULTS

All patients (median age: 78 years; range: 66-93) suffered from peripheral artery occlusive disease Rutherford stage 4 to 6 with a median lesion length of 12 cm (range: 7-35). Technical and procedural success was achieved in all 14 patients. The mean re-entry accuracy was 0.25 cm (range: 0-0.8). The SVS runoff score improved from a median of 14.5 (interquartile range IQR: 10.8-16.4) to 7 (IQR: 6.3-7) (p < 0.01).

CONCLUSIONS

The use of the Outback® catheter for targeted tibio-peroneal re-entry is associated with a high technical and procedural success rate and should be considered in case of otherwise failed ante- and retrograde recanalization.

Successful re-entry using the outback® elite catheter via retrograde popliteal access with IVUS guidance for femoropopliteal occlusion: a case report

Background

There are still cases that are difficult to treat for femoropopliteal chronic total occlusion (CTO). The Outback® Elite catheter is effective re-entry device to treat such kind of difficult cases, however, it might be difficult to use the Outback® Elite catheter antegradely in cases with severely calcified lesions. In this case, we performed EVT using the Outback Elite® catheter via the retrograde popliteal approach.

Case presentation

We report a case of a 77-year-old male with end-stage renal disease who presented with pain and cyanosis of his left foot. Control angiography showed total occlusion from the middle of the left superficial femoral artery to the proximal portion of the popliteal artery. The CTO lesion was severely calcified, which prevented the antegrade advancement of any guidewire. Retrograde popliteal puncture was performed with the patient in the supine position. After intentional retrograde subintimal wiring, the Outback® Elite catheter was advanced via the retrograde approach after the identification of a suitable re-entry site using intravascular ultrasound. After wire crossing, one nitinol stent was deployed and sufficient antegrade flow was achieved without any complications.

Conclusions

Using Outback® Elite from retrograde should be considered in cases where antegrade advancement fails and bidirectional wiring cannot pass through the CTO lesion.

Retrograde insertion of the outback reentry device from a tibial artery for complex infrainguinal recanalization

Introduction

Recanalization in an antegrade fashion in complex infrainguinal arterial disease can prove challenging and use of the Outback re-entry device via a retrograde approach may be an option.

Case presentation

Using an antegrade approach we were unable to cross the native occluded superficial femoral artery in a patient after two occluded bypasses, with ulcers and was unfit for general anaesthesia.

We successfully attempted retrograde re-entry using an Outback device via a phantom segment of the anterior tibial artery. After angioplasty and stenting a satisfactory result was achieved with one artery runoff.

Conclusions

At the 24 months follow up reconstruction was patent and ulcers were healed after 4 months.

The outcome of more cases will be decisive for the broader applicability of this technique.

The Aortic Bifurcation Angle as a Factor in Application of the Outback for Femoropopliteal Lesions in Ipsilateral Versus Contralateral Approaches

PURPOSE

To assess the technical success of the Outback reentry device in contralateral versus ipsilateral approaches for femoropopliteal arterial occlusion.

MATERIALS AND METHODS

A retrospective review of patients treated for critical limb ischemia (CLI) using the Outback between January 2013 and July 2016 was performed. Age, gender, length and site of the occlusion, approach site, aortic bifurcation angle, and reentry site were recorded. Calcification score was assigned at both aortic bifurcation and reentry site. Technical success was assessed.

RESULTS

During the study period, a total of 1300 endovascular procedures were performed on 489 patients for CLI. The Outback was applied on 50 femoropopliteal chronic total occlusions. Thirty-nine contralateral and 11 ipsilateral antegrade femoral were accessed. The device was used successfully in 41 patients (82%). There were nine failures, all in the contralateral approach group. Six due to inability to deliver the device due to acute aortic bifurcation angle and three due to failure to achieve luminal reentry. Procedural success was significantly affected by the aortic bifurcation angle (p = 0.013).

CONCLUSION

The Outback has high technical success rates in treatment of femoropopliteal occlusion, when applied from either an ipsi- or contralateral approach. When applied in contralateral access, acute aortic bifurcation angle predicts procedural failure.