The ReeKross™ catheter to treat long infragenicular vessel occlusionCourtesy of Dr. M Anderson, Dr. A D Platts, Department of Radiology, Royal Free Hospital NHS Trust, London NW3 2QG

IntroductionSubintimal recanalisation, also called percutaneousintentional extraluminal (subintimal) recanalisation(PIER) has been recognised as an important optionin the treatment of chronic critical limb ischemiasince 1990, when Bolia et al described their resultsin patients with femoropopliteal occlusion. Thisentailed intentionally entering the subintimal spacewith a guide wire from an antegrade approach,creating a loop in the lead portion of the guide wireand advancing the guide wire distally in thesubintimal space until it re-entered the true lumenbeyond the occlusion. Balloon angioplasty was thenperformed in the subintimal space to create anextraluminal channel to perfuse the lower leg (Ref 1).In 1994, Bolia et al reported the use of PIER in thetreatment of tibial occlusions and this technique wassoon adopted for infrageniculate vessels with goodresults (Ref 2-4). Difficulty often arises, particularlyin vessels below the knee, when attempting toadvance the loop and balloon catheter along thesubintimal plane. This can fail to propagate andlead to extravasation and thrombus formation. TheReeKross™ catheter has been shown to facilitate thisstage in supra-genicular vessels due to its very highpushability and the puncture-resistance of theballoon. Here we demonstrate the same benefits ofthe new ReeKross™ 3mm diameter balloon catheterused below the knee.

Patient HistoryAn 81 year old female patient presented with aninfected non-healing ulcer on the right 4th toe anddorsum of the foot due to chronic lower limbischemia. A Duplex scan found diffuse proximalatheroma without severe stenosis and advancedinfragenicular small vessel disease. Angiographyafter antegrade puncture showed no significantproximal disease to the distal popliteal artery.There was no continuous infragenicular vessel tothe foot. The peroneal artery was patent, filling agood calibre dorsalis pedis via distal collaterals.The posterior tibial artery was occluded throughoutand the anterior tibial artery (ATA) was occludedclose to its origin (Figs 1, 2 & 3).

Fig 1 Fig 2

Interventional Procedure It was decided to subintimally recanalise the ATA. The subintimal plane of the ATA stump was entered using a standard curved hydrophilic guidewire and a loop formed supported by a 3mm, 12cm long ReeKross™ balloon catheter on a 110cm shaft. The loop and balloon catheter were advanced smoothly and rapidly until the true lumen of dorsalis pedis was re-entered.

The ReeKross™ balloon was used to dilate the entire ATA back to its origin with easy dilatation and no balloon puncture (Fig 4).

Fig 1 Fig 2 Fig 3

Fig 4

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Discussion Subintimal angioplasty is a well established technique in the treatment of long vascular occlusions. Antegrade groin access is typically required to have the control to generate the needed force to "push" through the subintimal space particularly in the setting of calcified tibial vessels. This often also requires the use of an 0.018-inch (or even a 0.014-inch) balloon angioplasty system because the 0.035-inch balloon angioplasty catheters frequently fail to advance in the subintimal space due to distal resistance and proximal friction. Such pre-dilatation can lead to complications such as perforation and thrombus formation in the dilated subintimal space. Catheter exchange is laborious, time consuming and costly.

The advantage of the ReeKross™ system is that it is a durable system working with standard 0.035-inch guidewires. It typically does not require pre-dilatation to overcome friction resistance. It is very highly pushable leading to greater primary success rates, vastly shorter procedure time and reduced risk of complication.

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Angiography performed post – angioplasty demonstrated a smooth subintimal neolumen with rapid in-line flow to the dorsalis pedis and plantar arch (Figs. 5 - 7).

Fig 5 Fig 6

References

1. Bolia A, Miles KA, Brennan J, et al. Percutaneous transluminal angioplasty of occlusions of the femoral and popliteal arteries by subintimal dissection. Cardiovasc Intervent Radiol 1990; 13:357-363

2. Bolia A, Sayer RD, Thompson MM, et al. Subintimal and intraluminal recanalization of occluded crural arteries by percutaneous balloon angioplasty. Eur J Vasc Surg 1994; 8:214-219

3. Varty K, Bolia A, Naylor AR, et al. Infrapopliteal percutaneous transluminal angioplasty: a safe and successful procedure. Eur J Vasc Endovasc Surg 1995; 9:341-345

4. Ingle H, Nasim A, Bolia A, et al. Subintimal angioplasty of isolated infrageniculate vessels in lower limb ischemia: long-term results. J Endovasc Ther 2002; 9:411-416

Fig 7