When and how to do retrograde or subintimal recanalization (Zertifizierung: Modul A Spezialkurs)

Recanalisation of complete occlusions is usually performed by the subintimal approach using a hydrophilic wire irrespective of site. It is difficult to know how much of a recanalisation path is truly luminal or extraluminal but clues can be obtained from the shape and ease of passage of the wire and the lack of indentation on the balloon when in the subintimal space.

Subintimal recanalisation may be performed antegradely or retrogradely or both as in the “Safari” technique (Gandini et al).

Access to the subintimal space is achieved just before the occlusion. A shaped catheter such as a cobra is often used and the tip pointed away from adjacent collaterals. The hydrophilic wire forms an acute loop and this loop is advanced with step by step catheter support until the patent true lumen is re-entered. The loop visibly narrows and loss of resistance to movement of the guidewire informs the operator when the true lumen has been re-entered. This is confirmed by back bleeding from the catheter lumen and contrast injection.

Re-entry of the true lumen may fail in heavily diseased and calcified arteries, in which case re-entry devices may be useful or an alternative retrograde or antegrade approach can be performed.

Reference

The “Safari” technique to perform difficult subintimal infragenicular vessels. Gandini R et al CVIR 2007;30:469 – 73

Lernziele:

• It is often not possible to recanalise arterial occlusions totally intraluminally

• Use of the hydrophilic wire preferentially allows subintimal recanalisation with a high rate of success.

• Heavily calcified arteries impair re-entry into the true lumen

• Angioplasty and stenting techniques and results do not substantially differ whether recanalisation is luminal or extra-luminal.

E-Mail: [e-mail]