Extravascular Revascularization of a Chronic Total Occlusion Using the Dual Bull's-Eye Technique

To describe the dual bull's-eye technique to achieve successful extravascular revascularization of an occlusion after vessel perforation when the antegrade and retrograde catheters are too far apart for salvage with a reentry catheter.

The dual bull's-eye technique, which is an adaptation of the "gun-sight" method for transjugular portosystemic shunt procedures, is demonstrated in a popliteal artery occlusion in which multiple recanalization attempts have produced vessel perforation. Via antegrade femoral and retrograde anterior tibial artery accesses, 10-mm Amplatz GooseNeck snares were advanced in plane from each access to rendezvous in the popliteal fossa to obtain through-and-through wire access. A 15-cm Chiba needle was advanced percutaneously in plane through both snares, and a hydrophilic guidewire was maneuvered across an extravascular tract parallel to the popliteal artery. The tract was carefully predilated, and a 5×100-mm Viabahn stent-graft was deployed across the extravascular tract.

Owing to potential complications (limited patency, injury to adjacent structures) and only single-case use, this new technique should be considered a bailout strategy exclusively employed for limb salvage when traditional methods have failed and there are no viable surgical options.