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An Innovative Approach to Facilitate True Lumen Re-entry from Subintimal Track in Chronic Total Occlusions

Case Files with Dr. George

An Innovative Approach to Facilitate True Lumen Re-entry from Subintimal Track in Chronic Total Occlusions

Author Information:

Vincent Varghese, DO and Jon C. George, MD


As technology and expertise continue to expand in the endovascular treatment of peripheral arterial disease, revascularization rates are progressively improving. An integral component of this success is due to the development of re-entry devices for the treatment of long chronic total occlusions. Using angiographic or ultrasound guidance, these devices allow for re-entry into the vessel true lumen from the subintimal layer. We describe a case utilizing this technology with an innovative approach to guide needle puncture and wire advancement.



Case Report

A 72-year-old male with a 5-year history of lifestyle limiting bilateral lower extremity claudication was evaluated by peripheral angiogram. Right femoral angiogram revealed total occlusion of the right common iliac artery (CIA). Left femoral angiogram revealed total occlusion of the left CIA. The length of occlusion was noted to be 5 cm on the right and 10 cm on the left. Subsequent aortogram from left brachial artery access confirmed complete occlusion of the distal abdominal aorta with collaterals filling both iliac arteries (Figure 1). A Wildcat CTO device (Avinger, Redwood City, California) was advanced retrograde through the right CIA occlusion to successfully cross into the distal abdominal aorta with intraluminal position confirmed by contrast injection. Balloon angioplasty was performed within the right CIA with an Evercross 8 x 80 mm balloon (ev3 Inc., Plymouth, Minnesota) with modest improvement of stenosis and significant vessel recoil. The Wildcat device (Avinger) was then advanced retrograde through the left CIA occlusion but entered a subintimal dissection plane. After multiple unsuccessful attempts with wires and support catheters to cross into the true lumen, an Outback Re-entry device (Cordis Endovascular, Warren, New Jersey) was used to attempt re-entry. Due to significant distal aortic disease and vessel recoil, the puncture needle and wire were unable to re-enter the true lumen. The Evercross 8 x 80 mm inflated balloon (ev3 Inc.) was then positioned in the distal aorta as a target for the Outback catheter (Cordis) (Figure 2) while the needle was advanced to puncture the balloon. The wire was then advanced into the abdominal aorta with intraluminal position confirmation with contrast injection. Bilateral CIA simultaneous kissing balloon angioplasty was then performed without complication, with reconstruction of the aortoiliac bifurcation using a total of 4 balloon expandable covered stents. Final angiogram showed a patent abdominal aorta and bilateral CIA with brisk flow down both lower extremities (Figure 3).


Re-entry devices have transformed the world of endovascular medicine and supported the successful revascularization of PAD, a condition that was once only operable. The Outback re-entry device uses angiographic guidance to position a puncture needle to enter the true lumen and advance a wire to make stent-supported angioplasty feasible.1,2 True lumen re-entry is highly successful, 87% in femoropopliteal and 91% in aortoiliac occlusions, as demonstrated in a single-center study.3 Factors such as vessel position, tortuosity, severe calcification, and plaque burden often make re-entry challenging. We present a case with an innovative approach to facilitating re-entry, using an inflated balloon as a “target” for needle puncture and wire entry when conventional re-entry is unsuccessful. This technique allows for 3-dimensional visualization of the target lumen while stabilizing the vascular structure without movement, which likely improves success of re-entry. In complex anatomical situations, this method may offer incremental benefit and success in revascularization.


  1. Jacobs DL, Motaganahalli RL, Cox DE, Wittgen CM, Peterson GJ. True lumen re-entry devices facilitate subintimal angioplasty and stenting of total chronic occlusions: Initial report. J Vasc Surg. 2006 Jun;43(6):1291-1296.
  2. Hausegger KA, Georgieva B, Portugaller H, Tauss J, Stark G. The outback catheter: A new device for true lumen re-entry after dissection during recanalization of arterial occlusions. Cardiovasc Intervent Radiol. 2004 Jan-Feb;27(1):26-30.
  3. Etezadi V, Benenati JF, Patel PJ, Patel RS, Powell A, Katzen BT. The reentry catheter: A second chance for endoluminal reentry at difficult lower extremity subintimal arterial recanalizations. J Vasc Interv Radiol. 2010 May;21(5):730-734.


From the Deborah Heart and Lung Center, Browns Mills, New Jersey.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted June 17, 2011, provisional acceptance given July 11, 2011, final version accepted July 27, 2011.
Address for correspondence: Dr. Jon C. George, MD, Deborah Heart and Lung Center, Interventional Cardiology and Endovascular Medicine, 200 Trenton Road, Browns Mills, NJ 08015. E-mail:

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