Abstract
The CrossBoss chronic total occlusion catheter has been developed for the treatment of coronary chronic total occlusions. We report a novel use of the CrossBoss catheter for the crossing of a superficial femoral artery chronic total occlusion in three patients after conventional guidewire techniques failed.
1
Introduction
Chronic total occlusions (CTOs) of the superficial femoral artery (SFA) may be challenging to cross, especially long occlusions in calcified vessels. We report three cases in which use of the CrossBoss catheter (BridgePoint Medical, Minneapolis, MN, USA) succeeded in crossing an SFA CTO after conventional guidewire techniques failed.
2
Case reports
2.1
Case 1
A 55-year-old man with a history of hypertension, hyperlipidemia, multiple percutaneous coronary interventions, coronary artery bypass graft surgery and aortobifemoral bypass surgery presented with progressive claudication. Computed tomography angiography of the pelvis and the lower extremities revealed a patent aortobifemoral graft with bilaterally occluded SFAs with poor distal run-off. Diagnostic peripheral angiography demonstrated patent iliac arteries with ostial occlusion of both the right and left SFA. The left SFA reconstituted distally, revealing an approximately 60-mm segment of occlusion ( Fig. 1 A ).
The patient was considered high risk for a repeat peripheral bypass surgery and was referred for endovascular intervention, starting with the left SFA. After obtaining right common femoral artery access, a 45-cm-long, 6-Fr sheath was advanced into the left external iliac artery, and unfractionated heparin was administered for anticoagulation. The proximal cap of the left SFA CTO was successfully crossed with a 0.018″ Treasure guidewire (Abbott Vascular, Santa Clara, CA, USA) through a support microcatheter (QuickCross, Spectranetics, Colorado Springs, CO, USA); however, we could not cross the distal segment of occlusion as the guidewire preferentially entered a large vessel that originated at the distal cap ( Fig. 1 B). We subsequently exchanged the 0.018″ guidewire for a 0.014″ guidewire and inserted the CrossBoss catheter. Using the fast spin technique, the lesion was successfully crossed without difficulty and without entering the side branch ( Fig. 1 C). After confirmation of intraluminal catheter position ( Fig. 1 D), laser atherectomy with a 2.0-mm catheter (Spectranetics) and balloon angioplasty with a 5.0×60-mm Angioslide balloon (Angioslide, Inc., Minneapolis, MN, USA) were performed. Due to suboptimal result, the vessel was stented with 6.0×60-mm and 6.0×100-mm self-expanding stents (SMART, Cordis Corporation, Warren, NJ, USA) ( Fig. 1 E). The patient had an uneventful recovery with marked improvement in left lower extremity claudication.
2.2
Case 2
A 59-year-old man presented with progressive, severe left calf claudication. Diagnostic peripheral angiography demonstrated patent iliac and occluded SFA arteries bilaterally with distal left SFA reconstitution via collaterals from the profunda femoral artery (estimated occlusion length: 280 mm) and bilateral three-vessel distal run-off ( Fig. 2 A ). Given the patient’s left-sided symptoms, endovascular treatment of the left SFA CTO was elected.
A 6-Fr, 45-cm-long sheath was inserted in the right femoral artery and advanced over the aortic bifurcation into the left common femoral artery. Anticoagulation was achieved with unfractionated heparin. Multiple attempts at crossing the proximal cap with a 0.035″ stiff Glidewire Advantage (Terumo, Somerset, NJ, USA) were unsuccessful. The Glidewire was exchanged for a 0.014″ guidewire, and a CrossBoss catheter was inserted proximal to the lesion and promptly crossed the lesion into the distal true lumen ( Fig. 2 B, C). After confirmation of intraluminal wire position ( Fig. 2 D), the lesion was predilated with a 4.0- and 5.0-mm balloon and stented with two overlapping 6.0×150-mm self-expanding stents (SMART, Cordis) with an excellent final angiographic result ( Fig. 2 E). The patient had an uneventful recovery with resolution of the left lower extremity claudication.
2.3
Case 3
A 79-year-old man with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, tobacco use, multiple percutaneous coronary interventions and bilateral SFA stenting 2 years prior presented with an 8-month history of recurrent bilateral lower extremity claudication. Diagnostic peripheral angiography demonstrated patent iliac arteries bilaterally, occluded right and left SFA stents ( Fig. 3 A , B) and bilateral single-vessel distal run-off. After surgical evaluation, the patient elected to pursue endovascular treatment, and intervention in the left SFA in-stent restenotic lesion was planned.
A 7-Fr, 45-cm sheath was advanced over the aortic bifurcation into the left common femoral artery. Anticoagulation was achieved with unfractionated heparin. Several attempts were made to cross the occluded left SFA stent with a 0.035″ stiff Glidewire Advantage (Terumo), without success. The 0.035″ Glidewire was exchanged for a 0.014″ guidewire, and a CrossBoss catheter was inserted proximal to the occlusion. After some initial difficulty engaging the occlusion, the catheter successfully crossed the occluded stent segment into the distal true lumen. After confirmation of intraluminal wire position ( Fig. 3 C), the lesion was treated with a 5.0×60-mm Angiosculpt balloon (Angioscore, Inc., Fremont, CA, USA). Due to persistent stenosis in the distal edge of the previously placed stent, a 6.0×60-mm self-expanding stent (SMART, Cordis) was deployed with good final angiographic result ( Fig. 3 D). The patient subsequently successfully underwent right SFA endovascular treatment with significant claudication improvement.
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