Trans-Patch Retrograde Re-Entry During Hybrid Revascularization of an External Iliac Artery Chronic Total Occlusion: A Technical Note and Review of Re-Entry Strategies.

Failure of true-lumen re-entry after subintimal wire passage is a well-recognized limitation of endovascular treatment for external iliac artery (EIA) chronic total occlusions (CTO). We report a 73-year-old woman with severe limb ischemia and a prior failed endovascular attempt who underwent hybrid left common femoral artery (CFA) endarterectomy with patch angioplasty, followed by trans-patch retrograde access and dedicated device-assisted re-entry (Outback Elite) after antegrade and retrograde wires repeatedly tracked subintimally without reaching the true lumen. Controlled re-entry preserved hypogastric artery flow and allowed drug-eluting stent reconstruction of the EIA. At 12-month follow-up, ABI improved from 0.36 to 0.50, and TBI improved to 0.37. Duplex ultrasound at 6-month follow-up confirmed patency of the reconstructed segment without evidence of hemodynamically significant restenosis. This technical report illustrates the use of an endarterectomized CFA as a retrograde re-entry platform and reviews contemporary strategies for managing subintimal crossing failure in iliac CTOs.