Percutaneous Intentional Extraluminal Recanalization of Chronic Total Occlusions: A Review of Reentry Devices

Percutaneous intentional extraluminal recanalization (PIER) is an endovascular subintimal crossing technique used to treat chronic total occlusions (CTOs) of the peripheral arteries. Intraluminal revascularization remains the standard over PIER when technically feasible; however, when intraluminal approaches fail, PIER may be preferred prior to pursuit of surgical bypass grafting. The major cause of failure of PIER is inability to reenter the true lumen after crossing the CTO. Therefore, several reentry devices and endovascular techniques have been developed to allow for the operators to safely and quickly access the true lumen distal to the occlusion. Reentry devices currently available on the market include the Pioneer Plus catheter, Outback Elite catheter, OffRoad catheter, Enteer catheter, and GoBack catheter. These devices have unique methods of use and specific advantages with regard to their technical success along with reduced procedural and fluoroscopic time. In addition, there are other endovascular techniques available that may facilitate true lumen reentry and these will also be reviewed.