Abstract
Superficial femoral artery (SFA) is commonly diseased in patients with symptomatic peripheral arterial disease. Endovascular treatments have been more effectively used for SFA occlusions with new techniques and devices. Retrograde popliteal access has been used as an alternative to increase the success rate of percutaneous transluminal angioplasty (PTA) of SFA after a failed antegrade attempt. Although orbital atherectomy (OA) has been used effectively to treat SFA occlusions, there are no reports of use of OA by retrograde popliteal approach.
1
Introduction
Peripheral arterial disease involving the femoropopliteal arterial segment is characterized by long, diffuse lesions and long total occlusions . SFA occlusions are usually approached by an antegrade ipsilateral or retrograde contralateral common femoral approach with a “cross-over technique” and intraluminal or subintimal recanalization of the lumen. An alternative of accessing the popliteal artery and retrograde approach can be used when there is SFA origin occlusion, adverse collateral anatomy and inability to advance the wire antegradely. Orbital atherectomy, using the DiamondBack360® device, has been reported to decrease the need for stenting in a retrospective, non- randomized study which had also no control arm with balloon angioplasty and has been successfully used in treatment of peripheral arterial disease with a favorable safety profile . OA has been used in antegrade fashion and to our knowledge there is no reported use of OA in a retrograde fashion. Herein, we report a case in which we successfully performed percutaneous revascularization of an occluded SFA using retrograde OA via popliteal approach.
2
Case report
A 65 year old male with a history of hypertension, Diabetes Mellitus, hyperlipidemia and ischemic cardiomyopathy presented for an elective intervention of left SFA due to class 4 claudicating despite maximal medical treatment. Ankle–brachial index (ABI) was 0.5 in the left lower extremity. Initially, right femoral artery was cannulated, after crossing over with a JR4 catheter a Terumo Long 6 Fr vascular sheath was placed. Angiogram revealed chronic total occlusion (CTO) of left SFA ( Fig. 1, 2 ). We were not able to cross the occlusion by antegrade approach despite using multiple wires. The patient was then placed in a prone position and the left popliteal artery was accessed under fluoroscopic guidance and a 6 Fr short, 6 cm sheath was placed in the popliteal artery.
The lesion was then successfully crossed with a retrograde approach via a Confianza Pro 12 ( Asahi Intecc Co., Nagoya, Japan ) and then it was exchanged to viper wire ( ViperWire™, Cardiovascular Systems, Inc .) over a trailblazer support catheter ( ev3, Plymouth, MN ). Diamondback Predator atherectomy 2 mm burr ( Diamondback 360 º ™ Orbital Atherectomy System (OAS), Cardiovascular Systems, Inc., St. Paul, Minnesota) was used at low, medium and high speeds. In between the different level of speeds, 5–7 cc blood was aspirated from the popliteal sheath. Post atherectomy there was establishment of flow ( Fig. 3 ). Then balloon inflation was done with a 5×100 mm EverCross balloon ( ev3, Plymouth, MN ) at 10 ATM. Post PTA due to persistent Dissection ( Fig. 4 ) and significant recoil 7×100 mm Everflex self expanding stent ( ev3, Plymouth, MN ) was placed in mid SFA with an optimal final result ( Fig. 5 ).Total OA time was 5 min and bivalirudin was used during the procedure with an ACT above 220. Manual pressure applied for homeostasis 2 h after discontinuation of bivalirudin. Patient’s symptoms improved after the procedure and his ABI in the left leg 2 months after the procedure was 0.98.
