Application of the gunsight technique to facilitate subintimal arterial flossing with antegrade-retrograde intervention for the treatment of lower extremity chronic total occlusion

Objectives: Endovascular treatment of atheromatous chronic total occlusions (CTOs) of the lower extremity using the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) method may fail due to inability to position the antegrade and retrograde wires in the same plane. Failed attempted SAFARI in three limbs, in two patients, was rescued using a gunsight technique. Material and Methods: Retrospective procedure database review revealed three procedures where an occlusion could not be crossed despite antegrade and retrograde access which were treated using a novel technique for percutaneous puncture through antegrade and retrograde loop snares (gunsight technique). Results: Three limbs in two patients (mean age: 64 years) were treated using the gunsight technique. All three CTOs were successfully crossed and dilated with angioplasty and/or stents. A positive clinical outcome was achieved in each of the three affected limbs. Conclusion: The gunsight technique can improve technical success of SAFARI in the treatment of CTOs for atheroocclusive disease when there is failure to cross the lesion with standard endoluminal or subintimal approaches.