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Vascular intervention of superficial femoral artery (SFA) chronic total occlusions (CTO) is sometimes unsuccessful when the CTO cannot be crossed antegradely via contralateral or ipsilateral femoral approach because the proximal CTO cap is fibrocalcific or a CTO “nubbin” is absent.
We performed popliteal access to cross SFA CTOs retrogradely in 33 cases previously unsuccessfully attempted antegradely from contralateral/ipsilateral femoral approach. The popliteal artery was accessed using micropuncture needle with either fluoroscopic (n=27) or ultrasonographic guidance (n=6) with patient in a prone position. The distal cap of the SFA CTO was crossed with the Terumo guidwire and Trailblazer catheter, often using a loop in the Terumo guidewire to create a dissection plane. Reentry into the true lumen was confirmed by easy torquability of the Terumo guidewire in the proximal femoral, iliac arteries or the aorta after negotiating the entire length of the CTO. A 4 or 5 mm balloon was used to dilate the entire length of the CTO. Angiography was carried out to assess the result and stenting reserved for bailout in the event of slow flow or flow limiting dissection.Followup with arterial duplex ultrasonography or CT angiography was done in 2 weeks to evaluate vessel patency and repeated at 4 months to evaluate for restenosis.
In 28 cases brisk antegrade flow was reestablished and no additional intervention was necessary after plain balloon angioplasty. In 2 cases stenting of the focal dissection was carried out and in 3 cases the occlusion could not be crossed. Vessel were patent in 26 cases at 2 weeks imaging. Reocclusion in the 4 cases was reopened again via antegrade contralateral femoral access. All patients with successful intervention had relief of their claudication symptoms and/or rapid healing of the limb ulcers. Restenosis occurred in 5 cases by 4 months necessitating repeat intervention with Silverhawk atherectomy (n=4) or drug coated balloon (n=1).
Retrograde popliteal approach is successful in about 90% of cases of chronic SFA total occlusion interventions when antegrade crossing of the CTO from contralateral or ipsilateral femoral approach is unsuccessful.
ENDOVASCULAR: Peripheral Vascular Disease and Intervention