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ObjectiveThe acute technical failure of endovascular treatment of chronic total occlusions (CTOs) is most often due to the inability to re-enter the true lumen after occlusion is crossed in a subintimal plane. This study reports our initial experience with true lumen re-entry devices in the treatment of CTOs.MethodsPatients with treatment of CTOs were identified from our vascular registry. All patients in whom the Pioneer catheter or the Outback catheter were used were also identified from a prospectively maintained separate database of cases in which true lumen re-entry devices were used. We used procedural data from the prospective database and reviewed the medical records. Lesion character and location, access type, location of true lumen re-entry, stent usage, procedural times, and complications, were tabulated.ResultsFrom August 2003 to December 2004, endovascular techniques were used to treat 87 CTOs in 58 iliac and 29 superficial femoral arteries. In 24 (26%), the true lumen could not be re-entered by using standard catheter and wire techniques. The true lumen was not initially re-entered in 20 (34%) of 58 of treated iliac CTOs and four (13%) of 29 of treated superficial femoral artery CTOs (73% TASC C and D lesions). Intravascular ultrasound-guided true lumen re-entry using the Pioneer catheter (21 CTOs), or fluoroscopic-guided true lumen re-entry using the Outback catheter (3 CTOs) was successful in achieving true lumen re-entry in all cases at the location desired. Total time of re-entry catheter manipulation required to achieve re-entry was

Treatment of chronic total occlusions of the iliac and femoral-popliteal vessels with endovascular techniques has become the standard approach for shorter lesions and is increasingly applied to long, complex arterial occlusive lesions. As the complexity of the arterial occlusions increases, the demands for technical skills and devices needed to successfully cross and treat the occlusion also increases. We describe here our technique for treatment of iliac and femoral-popliteal occlusions. Important aspects of that that have allowed for a high technical success include (1) the use of hydrophilic wires and catheters to traverse occlusions in the subintimal plane, (2) femoral access with axially supported catheters or sheaths to apply the force needed for successful recanalization, and (3) the use of true lumen reentry devices when, after crossing the occlusion, the wire or catheter cannot be manipulated into the true lumen beyond the occlusion.

Hostile neck anatomy remains the predominant reason that patients are denied endovascular aneurysm repair (EVAR). We reviewed our experience of EVAR with use of prophylactic adjunctive proximal balloon-expandable stents in patients with hostile neck anatomy and adjunctive proximal balloon-expandable stents in patients with type I endoleaks. Of 140 patients who underwent EVAR between 2000 and 2004, we reviewed data for 19 patients in whom we used proximal balloon-expandable stents. By high-resolution computed tomography scan or angiography, hostile neck anatomy was classified as length

Percutaneous vascular closure devices have become increasingly common in their use in both cardiac and peripheral vascular intervention. Our cases present the risk factors of repeat percutaneous vascular closure devices for subsequent infectious complications. A 43-year-old male underwent cardiac catheterization and closure with an Angio-Seal (St. Judes Medical, Inc., St. Paul, MN) device. He required a second cardiac catheterization with access gained on the same side as the previous intervention. He developed bacteremia and an infected hematoma with erosion of the femoral artery. The second case involves a 57-year-old male who underwent cardiac catheterization and closure with an Angio-Seal device. He developed a localized infection over the accessed groin site. The overall complication rate of closure devices is 2%, and 0.3% of patients have infectious complications. The high morbidity associated with these complications indicates the need to be able to identify patients who are at increased risk for these complications.

Two techniques of vena cava filter placement with intravascular ultrasound (IVUS) guidance have been described previously. Placement with real-time IVUS imaging requires two venous access sites, one for the filter delivery system and one for the IVUS catheter, which makes the procedure more invasive. Alternatively, a single-access technique of IVUS imaging of the vena cava requires measuring the distance from the access site to the desired location for filter placement and then delivering the filter to that distance blindly, risking filter misplacement. We describe in this article a single puncture technique that allows for real-time imaging to position the filter delivery sheath using IVUS and reduces the uncertainty of the blind positioning of the filter delivery system.