Complex recanalization techniques for Complex femoro-popliteal lesions: How to optimize outcomes

Complex lesions within the femoro-popliteal vascular territory, amongst others, include more than 15 cm long or heavily calcified occlusions of the superficial femoral artery (SFA) or total occlusions of the popliteal artery (PA). For those type-C/-D lesions TASC-II recommendations originating from 2007 advocate bypass surgery as the therapy of choice if the patient is a suitable candidate for this. Against the background of evolving endovascular techniques which often allow recanalization of even long and calcified lesions as well as improved patency rates after endovascular treatment of such complex lesions, many vascular specialists go for an endovascular-first approach for the treatment of challenging lesions, last but not least in those patients unfit for surgery or in those lacking an adequate conduit or distal target vessel segment. This review focuses on two important aspects of treating complex femoro-popliteal lesions by an endovascular approach. The first part covers techniques to pass a complex lesion with a guidewire, while the second discusses strategies to improve the outcome of the endovascular reconstruction in terms of patency and clinical success.