Retrograde Use of Re-Entry Catheter for Revascularization of Superficial Femoral Artery Chronic Total Occlusion

Case Files by Dr. George

Submitted on Tue, 06/04/2013 - 16:24

Eric Rosen, DO, Jon C. George, MD

ABSTRACT: Endovascular revascularization of chronic total occlusions, albeit challenging, has become more appealing with evolving technology and innovative approaches. Retrograde use of a re-entry catheter allows an alternative strategy for revascularization when antegrade approaches fail. We present herein such a case with excellent angiographic result and outcome.



Case Report

A 64-year-old male presented with bilateral claudication symptoms, with symptoms greater in the right than the left lower extremity, that have severely limited his lifestyle and activities of daily living. His past medical history was significant for coronary artery disease with bypass graft surgery, ischemic cardiomyopathy with severely diminished ejection fraction, chronic kidney disease, hypertension, and dyslipidemia. Physical examination revealed bilateral dorsalis pedis and posterior tibial pulses present only using Doppler. Calculated Ankle Brachial Indices were severely reduced at 0.68 in the right lower extremity and 0.58 in the left lower extremity. Diagnostic peripheral angiography performed revealed bilateral chronic total occlusion (CTO) of the superficial femoral arteries (SFA) with 3-vessel runoff to the right foot and 2-vessel runoff to the left foot.

Percutaneous intervention of the right SFA CTO was initiated using left common femoral access with advancement of a 7 French Ansel sheath (Cook Medical) over an Amplatz stiff wire (Cook Medical) across the aortoiliac bifurcation into the right common femoral artery. Selective angiogram of the right common femoral artery revealed a 100% heavily calcified occlusion of the right SFA with reconstitution of the popliteal artery via collaterals from the profunda femoral artery and 3-vessel runoff into the right foot (Figure 1). Multiple attempts at revascularization via the antegrade approach were unsuccessful despite the use of CTO catheters, looped glidewires, and stiff wires repeatedly entering the subintimal space. However, the distance from the reconstituted vessel prevented the antegrade use of a re-entry catheter. 

Next, the right popliteal artery was accessed using ultrasound guidance with a micropuncture access kit and a 2.9 French pedal access kit sheath (Cook Medical) (Figure 2) to define the distal occlusion cap by angiography. A SurePath guidewire (IDEV) was advanced in retrograde fashion up to the proximal SFA but entered a subintimal plane adjacent to the true lumen and was again unsuccessful in entering the true lumen secondary to heavy calcification. An Outback re-entry catheter (Cordis) was then advanced over the SurePath guidewire in the subintimal plane to the proximal superficial femoral artery (Figure 3).

Using orthogonal views, the needle was advanced successfully into the true lumen, allowing the wire to be advanced to the common femoral artery. Balloon angioplasty was then performed through the occluded segment and re-entry point with good expansion. Two Viabahn covered stents (Gore) were then deployed in the SFA via the popliteal access and post dilated with a Submarine Plus 6 x 150 mm balloon (Medtronic), with good angiographic result and brisk flow through the entire SFA.

The popliteal artery sheath was then removed and hemostasis achieved using balloon tamponade of the intraluminal popliteal artery access site with the Submarine Plus balloon for a duration of 5 minutes (Figure 4). Final angiography revealed excellent result with brisk flow through the entire SFA and popliteal artery with 3-vessel runoff to the right foot (Figure 5).

The left common femoral artery sheath was then removed and hemostasis was achieved using a Mynx vascular closure device (AccessClosure). The patient was monitored overnight with no complications and discharged home the following morning on dual antiplatelet therapy.


Chronic total occlusions (CTO) of the peripheral arteries can cause disabling symptoms. Revascularization is indicated for patients with claudication, ischemic rest pain, or impending limb loss. Although endovascular treatment of short lesions of the iliac and femoropopliteal arteries has become the standard approach, longer complex lesion interventions can be challenging and time consuming with failure rates for iliac and femoropopliteal CTO as high as 5% to 25%, and 15% to 25%, respectively.1 Rapid advances of interventional devices have inspired interest in tackling these occlusions, with success rates as high as 85% and almost 100% utilizing CTO catheters and re-entry devices, thus reserving surgery only if endovascular techniques are unsuccessful.2-4 

CTOs consist of various degrees of fibroatheromatous plaque and thrombus depending on the mechanism and duration of occlusion. A tough fibrous cap is often present at the proximal end, with softer material found in the mid and distal segments of the occlusion. As a result, the retrograde approach is often successful to traverse the occluded segment when the antegrade approach fails. In a randomized study of 100 patients, retrograde revascularization was found to be technically easier with a tendency toward fewer complications, such as vessel perforation, dissection, and hematoma formation, but resulted in higher fluoroscopy time.3

An Outback re-entry catheter was required to re-enter the true lumen from the subintimal space via retrograde popliteal access. The Outback is a 6 French catheter that contains a 22-gauge angled needle that can be advanced or retracted from the end of the catheter to penetrate the dissection plane into the true lumen. The angle of the catheter is adjusted to point toward the true lumen using orthogonal fluoroscopic views. A 0.014-inch wire is then advanced into the true lumen and the Outback catheter is then removed, to allow balloon angioplasty or stent deployment over the wire as desired.5 Routinely, re-entry is performed in antegrade fashion into the true reconstituted lumen in the distal vessel beyond the occlusion. On rare occasions when the antegrade approach fails, a retrograde re-entry strategy may be employed. While this approach requires at least a 6 French access in a distal artery, it facilitates faster traversal through the distal occlusion cap and reduces the risk of perforation or extravasation from failed needle punctures at the re-entry site. We present herein the retrograde use of a re-entry catheter for revascularization of SFA CTO with excellent angiographic result. 


  1. Lofberg A, Karacagil S, Ljungman C. Percutaneous transluminal angioplasty of the femoropopliteal arteries in limbs with chronic critical lower limb ischemia. J Vasc Surg. 2001;34(1)114-121.
  2. Smith BM, Stechman M, Gibson M, Torrie EP, Magee TR, Galland RB. Subintimal angioplasty for superficial femoral artery occlusion: poor patency in critical ischaemia. Ann R Coll Surg Engl. 2005;87(5):361-365.
  3. Yilmaz S, Sindel T, Yegin A, Lüleci E. Subintimal angioplasty of long superficial femoral artery occlusions. J Vasc Interv Radiol. 2003;14(8):997-1010.
  4. Ko YG, Kim JS, Choi DH, Jang Y, Shim WH. Improved technical success and midterm patency with subintimal angioplasty compared to intraluminal angioplasty in long femoropopliteal occlusions. J Endovasc Ther. 2007;14(3):374-381.
  5. Wiesinger B, Steinkamp H, König C, Tepe G, Duda SH. Technical report and preliminary clinical data of a novel catheter for luminal re-entry after subintimal dissection. Invest Radiol. 2005;40(11):725–728.



Editor’s Note: Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. George reports consultancy to Cordis. Dr. Rosen reports no disclosures related to the content of this artilcle.

Manuscript received April 16, 2013; final version accepted April 18, 2013.

Address for correspondence: Jon C. George, MD, Director of Clinical Research, Division of Cardiovascular Medicine, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ, 08015, USA. Email: n