Abstract
Currently available techniques for the endovascular treatment of infrainguinal arterial chronic total occlusions (CTOs) require long procedure duration, large contrast volumes, complex subintimal dissection technique, and have low-intermediate success rates. Inability to remain intraluminal and/or reenter the true lumen after subintimal dissection remains the main reasons for procedural failure. We report for the first time a novel, simple, and reproducible technique that can significantly improve both the success and safety of endovascular intraluminal crossing of totally occluded peripheral arterial segments: the transcutaneous ultrasound-guided (TUG)-CTO technique. We used transcutaneous ultrasound guidance to cross long segments of superficial femoral artery CTO using a blunt-microdissection technique.
1
Introduction
More than one half of all lesions encountered during lower extremity percutaneous revascularization procedures are chronic total occlusions (CTO) in the infrainguinal peripheral arterial segments, most commonly in the superficial femoral artery (SFA) . Crossing these CTO lesions may be challenging requiring prolonged procedures, significant radiation exposure for the patient and operator, large iodinated contrast load for the patient, and use of complex subintimal dissection techniques and specialized reentry devices to allow true lumen reentry . Success rates are low (50% to 70%) with inability to remain intraluminal and/or reenter the true lumen after subintimal dissection being the main reasons for failure . Moreover, there is a risk of perforation, dissection, and creation of arteriovenous fistulas .
In this report, we provide for the first time a case-based description of a novel technique for percutaneous endovascular crossing of long and complex infrainguinal CTOs, using transcutaneous ultrasound-guided (TUG) blunt microdissection.
2
Technique description and case presentation
A 52-year-old white man, with diabetes mellitus and chronic kidney disease (CKD), presented with Rutherford category 3 claudication symptoms in both lower extremities. The ankle-brachial indices (ABI) in the right and left lower extremity were 0.51 and 0.53, respectively. Angiography revealed patent common iliac, external iliac, common femoral, and profunda femoris arteries bilaterally. The left SFA was occluded proximally and reconstituted distally at the level of the adductor canal ( Fig. 1 A and B) (estimated length of occlusion: 300 mm). The left popliteal artery was patent with two-vessel infrapopliteal run-off. The right SFA also had a 140-mm CTO with above-the-knee distal reconstitution and two-vessel infrapopliteal run-off.
The patient declined surgical intervention and requested percutaneous revascularization. Given the complexity of bilateral CTO and the presence of CKD, we aimed to cross the left SFA CTO using blunt microdissection technique with the Frontrunner catheter (Cordis, Warren, NJ, USA; Fig. 1 J) under transcutaneous ultrasound (US) guidance in addition to fluoroscopy. The occluded proximal left SFA was engaged using the Frontrunner catheter loaded inside a hydrophilic microguide catheter ( Fig. 1 C and G). It was maneuvered under US guidance (jaws open, Fig. 1 H; jaws closed, Fig. 1 I) to penetrate the proximal cap, then advanced through the mid segment (closed jaws) and then retracted (open jaws) to create a larger channel for the microguide catheter to follow. All catheter manipulations were performed under “real-time” US guidance, securely within the true lumen of the occluded vessel ( Fig. 1 F–I). Ultimately, the microdissection catheter was advanced across the distal cap of the CTO and distal vessel true lumen access was confirmed by demonstrating duplex flow ( Fig. 2 A ). The Frontrunner catheter was removed and injection of agitated saline through the microguide catheter under US guidance and iodinated contrast under fluoroscopic guidance confirmed the intraluminal position. The microguide catheter was replaced with a 0.018-in., 260-mm-long SV5 (Cordis) guidewire. The lesion was then predilated with a 5×220-mm Savvy balloon (Cordis) ( Fig. 1 D) and stented with overlapping 6×150, 6×150, and 6×60-mm Smart Control (Cordis) self-expanding nitinol stents. The stented segment was postdilated with a 5×220-mm Savvy balloon with excellent angiographic ( Fig. 1 E) and duplex US-confirmed result ( Fig. 2 B and C). The procedure was accomplished using 23 min of fluoroscopy and 80 ml of iodinated contrast. A week later, the right SFA CTO was successfully crossed using the same TUG blunt-microdissection technique and after suboptimal angioplasty result, stented with two overlapping 6×80-mm Smart Control (Cordis) self-expanding nitinol stents, using only 60 ml of contrast and 16 min of fluoroscopy ( Fig. 3 A –G). The patient had no increase in his serum creatinine and reported significant improvements in walking distance. The ABIs were 0.91 on the right and 0.89 on the left lower extremity postinterventions.
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