An 81 y-old patient presented with extensive infected leg ulcers and a rest pain. He had a history of one occluded femoropopliteal proximal bypass and two occluded femoropopliteal distal bypasses to the anterior tibial artery (ATA) and the tibioperoneal trunk (TPT) respectively.
The patient was referred to us for an attempt of endovascular recanalization under local anaesthesia. The patient, given his comorbidities, was unfit for general anaesthesia.
The right leg angiogram showed occlusion of the superficial femoral artery (SFA) with a short stump and a large collateral arising at a 45 degree angle (Fig. 1). The Popliteal artery (POP), the TPT and the posterior tibial artery were also occluded. The ATA was recanalised by collateral just after its origin to occlude again few centimetres below. ATA and peroneal artery (recanalised by collaterals at the level of its mid segment) were the vessels reaching the foot (ATA occluded at the dorsalis pedis passage) with posterior tibial artery recanalised at the ankle level by collaterals.
The right common femoral artery (CFA) was punctured in an antegrade fashion but any attempt to cross the native occluded SFA failed, being unable to engage the true lumen of the occluded SFA or even to start a subintimal dissection, despite the use of different combinations of wires and catheters..
The blind segment of the ATA was then punctured in a retrograde fashion under fluoroscopic guidance by a 21G needle (Fig. 2).
A V18 wire (Boston Scientific, Natick, Massachusetts), supported just by an 0.018 CXI catheter (Cook, Bloomington, Indiana) managed to reach the proximal SFA stump subintimally but all attempts at re-entry into the true lumen at that level failed.
The Outback re-entry device was then passed sheath-less from the ATA access on the 0.018 wire (Fig. 3). The Outback was aimed at the proximal stump of the SFA (Fig. 4), the re-entry was successful on the first attempt and the wire was snared out from the CFA sheath.
The distal access was then removed and a 3 mm balloon was inflated at that level for 3 min to seal the vessel.
The short occluded segment of the ATA just below entry site was recanalised intraluminally from the CFA access and stented using a 3.5 mm XIENCE Prime BTK Drug Eluting Stent (Abbott, Chicago, Illinois).
After subintimal angioplasty of the SFA, POP and proximal ATA, the latter was stented by a 4 mm XIENCE Prime BTK Drug Eluting Stent (Abbott, Chicago, Illinois). The POP and SFA also required stenting, performed by overlapping 5.5 mm Supera Stents (Abbott, Chicago, Illinois) and 6 mm Absolute Pro stent (Abbott, Chicago, Illinois) at the level of the proximal SFA.