The document describes the use of the ReeKross catheter to treat an occlusion of the anterior tibial artery (ATA) in an 81-year old female patient presenting with an infected non-healing ulcer on her right foot due to chronic lower limb ischemia. The subintimal plane of the occluded ATA was entered and the ReeKross catheter was used to advance smoothly through the subintimal space to reenter the true lumen beyond the occlusion. Balloon angioplasty with the ReeKross catheter then dilated the entire length of the ATA with easy dilatation and no balloon puncture, restoring blood flow to the foot as seen on follow up angiography. The Ree

1. The ReeKross™ catheter to treat long infragenicular vessel occlusion
Courtesy of Dr. M Anderson, Dr. A D Platts, Department of Radiology, Royal Free Hospital NHS Trust, London NW3 2QG
Introduction
Subintimal recanalisation, also called percutaneous
intentional extraluminal (subintimal) recanalisation
(PIER) has been recognised as an important option
in the treatment of chronic critical limb ischemia
since 1990, when Bolia et al described their results
in patients with femoropopliteal occlusion. This
entailed intentionally entering the subintimal space
with a guide wire from an antegrade approach,
creating a loop in the lead portion of the guide wire
and advancing the guide wire distally in the
subintimal space until it re-entered the true lumen
beyond the occlusion. Balloon angioplasty was then
performed in the subintimal space to create an
extraluminal channel to perfuse the lower leg (Ref 1).
In 1994, Bolia et al reported the use of PIER in the
treatment of tibial occlusions and this technique was
soon adopted for infrageniculate vessels with good
results (Ref 2-4). Difficulty often arises, particularly
in vessels below the knee, when attempting to
advance the loop and balloon catheter along the
subintimal plane. This can fail to propagate and
lead to extravasation and thrombus formation. The
ReeKross™ catheter has been shown to facilitate this
stage in supra-genicular vessels due to its very high
pushability and the puncture-resistance of the
balloon. Here we demonstrate the same benefits of
the new ReeKross™ 3mm diameter balloon catheter
used below the knee.
Patient History
An 81 year old female patient presented with an
infected non-healing ulcer on the right 4th toe and
dorsum of the foot due to chronic lower limb
ischemia. A Duplex scan found diffuse proximal
atheroma without severe stenosis and advanced
infragenicular small vessel disease. Angiography
after antegrade puncture showed no significant
proximal disease to the distal popliteal artery.
There was no continuous infragenicular vessel to
the foot. The peroneal artery was patent, filling a
good calibre dorsalis pedis via distal collaterals.
The posterior tibial artery was occluded throughout
and the anterior tibial artery (ATA) was occluded
close to its origin (Figs 1, 2 & 3).
Fig 1 Fig 2
Fig 1 Fig 2 Fig 3
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 4

2. 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.
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
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Fig 7