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In this highlighted case of the month, we review the approach for a femoro-popliteal in-stent reocclusion in an 86 years old female patient with multiple comorbidities, previously stented on the superficial femoral artery and popliteal arteries, presenting with severe left foot pain at rest and critical limb ischemia. Physical exam was pertinent for the absence of left popliteal pulse and a lower limb ultrasound showed an occlusion of the previously implanted stents. A CT-angiography scan showed an in-stent reocclusion of the stents.

Educational Objectives

  • Plan a step-by-step approach in treating SFA in-stent reocclusion.
  • Learn how and when to use Rotarex drive system.
  • Discuss treatment by drug-coated balloon vs Viabahn endoprosthesis.
  • Discuss bypass vs angioplasty.


Plan A

  • Right common femoral artery access and a cross-over procedure 6 Fr.
  • 0.018" guidewire and support catheter.
  • Thrombectomy +/- Viabahn.

Plan B

  • Retrograde access/direct puncture of occluded stents.

Step-by-step procedure:

1) Access site:

  • 6 Fr braided sheath from the right common femoral artery and cross-over to the left using a 0.035" Cook stiff glidewire and 6 Fr Destination 45 cm guiding sheath.

2) Step by step approach:

  • Initial angiography showed severe stenosis of the ostial superficial femoral artery with occlusion of the two oversized implanted stents and a short distal occlusion of the antero-tibial artery.
  • In-stent crossing was performed using a 0.018" hydrophilic Advantage glidewire followed by a 0.018" Navicross support catheter.
  • Over-the-wire rotational thrombectomy was then performed using a Rotarex drive system.
  • Predilatation intra-stent and of the ostial superficial femoral artery was performed using a 4.0 mm balloon followed by PTA using 3 drug coated balloons of 5.0 mm.
  • Angiographic control showed >50% residual stenosis at the stent overlap level treated by a further dilation using a high pressure 6.0 mm Mustang balloon inflated to 26 atm.
  • The final angiographic outcome showed <30% residual stenosis and a clear dorsalis pedis pulse was noted.
  • Closure of access site using a femoseal was undertaken.






1. ​Pan, T.; Tian, S. yun; Liu, Z.; Zhang, T.; Li, C.; Ji, D. hua Combination of RotarexⓇS Rotational Atherothrombectomy and Drug-Coated Balloonangioplasty for Femoropopliteal Total In-Stent Occlusion. Ann. Vasc. Surg. 2022, 80, 213–222, doi:10.1016/J.AVSG.2021.08.058.
2. Yu, J.S.; Park, K.-M.; Jeon, Y.S.; Cho, S.G.; Hong, K.C.; Shin, W.Y.; Choe, Y.-M.; Shin, S.-H.; Kim, K.R. Midterm Outcome of Femoral Artery Stenting and Factors Affecting Patency. Vasc. Spec. Int. 2015, 31, 115–119, doi:10.5758/vsi.2015.31.4.115.
3. ​Gao, M.; Zhao, X.; Tao, Y.; Wang, L.; Xia, M.; Tong, Z.; Hou, C.; Hua, Y. Incidence and Predictors of In-Stent Re-Stenosis in the Superficial Femoral Artery: Evaluation of Long-Term Outcomes by Color Duplex Ultrasound. Ultrasound Med. Biol. 2016, 42, 717–726, doi:10.1016/J.ULTRASMEDBIO.2015.11.001.
4. Ye, M.; Ni, Q.; Zhu, Y.; Du, Y.; Wang, Y.; Guo, X.; Zhang, L.; Feng, Z. Stent Graft vs Drug-Coated Balloon in Endovascular Treatment of Complex Femoropopliteal Artery Lesions: A 2-Center Experience. https://doi.org/10.1177/15266028231201097 2023, doi:10.1177/15266028231201097.
Shooting date : 2022-06-05
Last update : 2024-04-17
Koen Deloose
Dendermonde, Belgium

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  • khalid S. Suppose the occluded stent is extending to P2, p3 segment, what to do in this situation, up to where we could land the viaban stent graft

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