A 0.035-inch hydrophilic guide wire (Radifocus Glidewire Terumo, Tokyo, Japan) and a 5-F Kumpe Slip-Cath catheter (Cook, Bloomington, Indiana) or C2 Glidecath Cobra catheter (Terumo) were used to cross the occluded segments with wire loop technique. A 6-F sheath was initially inserted in all cases. In all patients with iliac occlusions, a contralateral access was obtained to obtain an angiogram and acquire a roadmap image. Infra- inguinal occlusions were treated via an antegrade ipsilateral approach. Suprainguinal occlusions represented 65% of cases and were treated via a retrograde ipsilateral approach. Patients were prescribed lifelong antiplatelet therapy with clopidogrel 75 mg/d or aspirin 81 mg/d. Patients with suprainguinal occlusions were treated with Express LD balloon-mounted stents (Boston Scientific) or Protege EverFlex self-expanding stents (ev3, Plymouth, Minnesota), and patients with infrainguinal occlusions were treated with Protege EverFlex self-expanding stents (ev3). When true lumen reentry had been obtained, the occluded segment was predilated with a 4- or 5-mm Sterling angioplasty balloon (Boston Scientific, Natick, Massachusetts). All patients underwent anticoagulation with 5,000 IU of heparin before recanalization was attempted. Arterial access was retrograde for iliac segment or antegrade for femoral and popliteal segments. All procedures were performed under local anesthesia and intravenous sedation. Demographic and procedure data are summarized in the Table. The recanalization time with the MTSN was recorded as the span of time between angiography recording the failed attempt and angiography performed through the needle after reentry of the true lumen. The time spent trying to recanalize the artery was recorded as the time between angiography performed for roadmap purposes before subintimal dissection and follow-up angiography demonstrating the failure to reenter the true lumen. The total procedure time was obtained from the technical procedure record. The lesion characteristics were classified according to the Trans-Atlantic Inter-Society Consensus (TASC) II (9). Occluded segment length was measured with coronal views, and vessel diameter was measured with axial views. All patients had preproce- dural assessment with computed tomographic (CT) angiography. An alternative technique with an MTSN was developed and used to reenter the true lumen of the occluded arteries. In 23 patients, it was not possible to reenter the true lumen with subintimal technique. All 98 patients identified were referred from the vascular surgery department for subintimal recanalization of chronic occluded iliac, superficial femoral, and/or popliteal arteries.

All patients had given informed consent before the procedure. The present study was conducted under institutional review board approval to retrospectively review all patients who underwent subintimal recanalization during the time period from December 2008 to December 2010. The present report describes an initial experience with a modified transseptal needle (MTSN) as an alternative reentry device in the endovascular treatment of chronic total occlusions of the iliac, femoral, and popliteal arteries.

The use of the proprietary reentry devices could be limited by cost and the need for additional equipment, such as that required by intravascular US. The reported technical success rate of the use of these devices in reentering the true lumen is approximately 95% (7,8).

To overcome this problem, there are two commercially available reentry devices: the Outback catheter (Cordis, Bridgewater, New Jersey), a fluoroscopic-guided 6-F, 120-cm catheter and the Pioneer catheter (Medtronic, Santa Rosa, California), an intravascular ultrasonography (US)–guided 6-F, 120-cm catheter (6,7). Acute technical failure caused by inability to reenter the true lumen when treating a patient with conventional subintimal angioplasty technique is seen in approximately 20% of cases (1–5). The technique was originally described by Bolia et al (1). angioplasty is a well established technique to recanalize chronic total occlusion of lower-extremity arteries.

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