Percutaneous Femoral-Popliteal Reconstruction Techniques: Reentry Devices



Percutaneous Femoral-Popliteal Reconstruction Techniques: Reentry Devices


Danielle E. Cafasso

Peter A. Schneider





PATIENT HISTORY AND PHYSICAL FINDINGS



  • Patients with clinical symptoms and signs of lower extremity ischemia may benefit from subintimal recanalization and the use of reentry techniques in the course of their clinical care.


  • Patients present with claudication, rest pain, nonhealing ischemic ulcers, or gangrene. The history and physical examination is consistent with these lower extremity presentations and is described elsewhere in this atlas.


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • Patients who might benefit from subintimal recanalization and reentry typically have complex lesion morphology, such as arterial occlusion, that may be managed by creating a new channel outside of the potential space offered by the subintimal area. Imaging studies that define the anatomy and lesion morphology are useful prior to revascularization. This may include duplex scanning, magnetic resonance angiography, or computerized tomographic angiography. We usually perform duplex mapping prior to any lower extremity intervention. Long lesions, occlusions, and complex lesions are typically identifiable with preoperative imaging.


  • Patients with lower extremity ischemia should have objective physiologic confirmation of the degree to which perfusion is diminished. This may be accomplished by ankle-brachial indices or toe pressures.


SURGICAL MANAGEMENT


Preoperative Planning



  • Preoperative planning includes identifying the best access site for arterial entry. Subintimal recanalization of the femoral-popliteal segment may be performed using an up and over approach, from the contralateral common femoral artery, or using an antegrade approach from the ipsilateral common femoral artery. A reentry catheter may be used through either of these access choices. Preoperative noninvasive imaging is very helpful in making this plan for approach.


  • The location of lesion helps determine access site and approach. Many patients with superficial femoral artery (SFA) and/or popliteal artery disease are treated with an up and over approach. If the patient has inflow iliac artery disease or has an SFA lesion that begins near the origin of the SFA, an up and over approach is warranted. Reentry devices require placement of a 6-Fr sheath. If an up and over approach is anticipated, the aortic bifurcation should also be assessed to make sure that the reentry device can be passed.


  • Patients with extensive disease below the knee and without iliac or proximal SFA disease and who are not obese can be treated using an antegrade approach.