Needle fenestration of popliteal artery covered stent graft to salvage inadvertent stent misdeployment

Endovascular methods have transformed treatment of lower extremity peripheral arterial disease but can still present technical challenges. We report the case of a 69-year-old man with rest pain who underwent superficial femoral artery recanalization with covered stents. During completion angiography, the distal stent was discovered to have been mis-deployed into an anterior geniculate branch overlying the behind-the-knee popliteal artery. Subsequently, an endo-vascular reentry device was used to fenestrate the stent posteriorly to enter the lumen of the popliteal artery. Cutting balloons were used to enlarge the fenestration in the stent fabric, with placement of an additional 6 x 50-mm covered stent bridging from the popliteal artery into the fenestrated misdeployed covered stent. Completion angiography demonstrated no evidence of distal embolization and patent two-vessel runoff. The patient had an uncomplicated re-covery and at 2 years of follow-up remained asymptomatic with documented popliteal stent patency.