"Through-the-strut" re-entry technique: a successful endovascular salvage of iatrogenic subintimal stent deployment in the common iliac artery

Abstract

Introduction: Endovascular-first strategies for aortoiliac occlusive disease (AIOD) are standard, yet they carry risks of iatrogenic complications. Subintimal stent deployment is a rare but limb-threatening event that traditionally requires emergency open surgery. This report describes a successful endovascular bailout using a novel through-the-strut re-entry technique. Case presentation: A 58-year-old male with diabetes and a 40 pack-year smoking history presented with rest pain and cyanosis of the right first toe (Rutherford 4). Imaging confirmed severe right common iliac artery (CIA) stenosis. During intervention, a 0.035” hydrophilic wire inadvertently created a subintimal dissection. A 7 – 57 mm balloon-expandable stent (Besmooth) was deployed within the false lumen, causing acute limb ischemia. The complication was managed by navigating a 5F JR catheter through the misplaced stent's struts to re-access the true lumen. After sequential balloon dilatation through the struts (4F to 7F), an 8 – 100 mm self-expanding Lifestent was deployed to re-line the artery, crushing the initial stent against the wall. Immediate blood flow was restored. The ankle-brachial index improved from 0.4 pre-procedure to 1.1 after intervention. At 6-month follow-up, the patient remained asymptomatic with a patent "stent-in-stent" complex on CTA. Conclusion: Iatrogenic subintimal stent deployment can be successfully salvaged through the "through-the-strut" technique. This approach avoids the high morbidity of emergency open bypass in high-risk patients and provide an effective endovascular bailout strategy to restore true lumen perfusion and avoid emergency surgical conversion in selected patients..