Retrograde use of the Outback™ re-entry catheter in complex infrainguinal arterial recanalizations

PURPOSE

Retrograde recanalizations gained increasing recognition in complex arterial occlusive disease. Re-entry devices are a well described adjunct for antegrade recanalizations. We present our experience with retrograde, infrainguinal recanalizations using the Outback™ re-entry catheter in challenging chronic total occlusions.

MATERIALS AND METHODS

We report data from a retrospective multicenter registry in complex retrograde recanalizations. Eligibility criteria included retrograde infrainguinal use of the Outback™ re-entry catheter where both conventional antegrade and retrograde recanalization had been unsuccessful. Procedural outcomes included technical success (defined as successful wire passage and delivery of adjunctive therapy with <30 % residual stenosis), safety (periprocedural complications, e.g. bleeding, vessel injury or occlusion of the artery at the re-entry site, and distal embolizations) and clinical outcome (amputation-free survival and freedom from clinically driven target lesion revascularization).

RESULTS

Forty-five consecutive patients underwent retrograde, infrainguinal recanalization attempts with the Outback™ re-entry catheter between February 2015 and August 2020. Thirty (67 %) patients had history of open vascular surgery in the index limb. In 4 patients, recanalizations were even more challenging due to previous surgical removal and/or ligation of the proximal segment of the superficial femoral artery. Retrograde access site of the Outback™ catheter was the femoropopliteal segment in 31 (69 %) patients and crural vessels in 14 (31 %) patients. The re-entry target sites were as follows: common femoral artery in 31 (69 %) patients, superficial femoral artery in 9 (20 %) patients, popliteal artery in 1 and below-the-knee arteries in 2 patients. In 4 patients, the needle of the re-entry device was targeted to an inflated balloon, inserted via the antegrade route. The Outback™ re-entry catheter was placed via a 6-French sheath in 19 (42 %) cases and sheathless in 26 (58 %) cases. Technical success was achieved in 41 (91 %) patients There were 2 instances of distal embolizations and 3 bleeding episodes. Amputation free survival was 100 % at 30 days and after 12 months, freedom from clinically driven target lesion revascularization (cd TLR) was 95 % at 30 days and 75 % at 12 months follow-up. Female sex was an independent predictor for cd TLR at 12 months follow-up.

CONCLUSION

Retrograde use of the Outback™ re-entry catheter in infra-inguinal chronic total occlusions provides an effective and safe endovascular adjunct, when conventional antegrade and retrograde recanalization attempts have failed.

Implantation of vascular mimetic implants in challenging chronic total occlusions - SuperaTM Extreme

Standard nitinol stents (SNS), with or without drug eluting technology, are an essential tool within the interventional armamentarium in the treatment of patients with peripheral arterial disease. However, they are plagued by a number of limitations: a.) stent fractures, although observed predominately in first-generation stents, do still occur in state-of-the art stent platforms, b.) lack of radial strength, resulting in inadequate stent expansion, c.) kinking up to a complete collapse of the stent, therefore compromising its use in areas of high mechanical stress such as bending zones. In contrast, the interwoven design of the Supera^TM stent, also referred to as "vascular mimetic implant", overcomes all of the above limitations of SNS. Several registries and studies not only confirmed its mechanical superiority (lack of stent fractures etc.) but also demonstrated remarkable clinical performance (patency and freedom from target lesion revascularization), despite its use in challenging lesions (calcification etc.) and territories (popliteal arteries etc.). Increasing confidence in the mechanical properties of the Supera^TM stent platform prompted interventionalists to further "push the limits" of this unique implant. The present article summarizes the clinical data and shows examples of "extreme" applications of this dedicated stent platform.