Background:
Although majority of cases with chronic total occlusion (CTO) in femoro-popliteal lesion were treated with antegrade approach only, some lesions require alternative approach due to its complexity. Bi-directional approach is useful on endovascular therapy (EVT) for CTO; however guidewire recanalization is impossible in some challenging cases. The present case shows a successful re-entry technique utilizing two snare catheters from an antegrade and retrograde access site (double snare piecing technique).
Case presentation:
A 79-year-old woman with right leg intermittent claudication (Rutherford category Ⅲ), who had undergone unsuccessful EVT for popliteal CTO, required another EVT for the worsening symptom. Following the failed conventional crossing technique, two snare catheters were placed and the snare loops were pierced by a puncture needle from the skin surface. After an 0.014 wire was inserted into the needle, the needle was withdrawn. The wire was pulled from the retrograde side and was externalized. Then, the antegrade snare catheter was pulled and externalized, to make the wire across the lesion. After that, a microcatheter was advanced along the externalized wire from the retrograde side and cross the lesion. The wire was replaced with a new wire, which completely created pull-through system. After the hemostasis by balloon inflation and lesion preparation, this procedure finished with an endoluminal-covered stent and two inter-woven stents. The re-entry site was covered by the inter-woven stent. She improved her symptom after the procedure, and the lesion has not developed restenosis at 2-years follow-up.
Conclusions:
This re-entry technique of puncturing two snares (double snare piercing technique) might be effective for challenging femoropopliteal CTO cases.