Keywords surgical ligationrevascularization - re-entry
Introduction
Critical limb ischemia is the “end stage” of the peripheral arterial disease, a clinical
condition representing an impending threat of amputation for many diabetic patients.
Their hope resides in revascularization procedures, especially endovascular ones,
thanks to the technological and technical advances made in the recent years.[1 ]
Still, these patients’ arterial chronic total occlusions hinder technical success.
In these cases, subintimal approach and an expert use of re-entry devices may help
interventionists to accomplish arterial revascularization.[2 ]
Case Report
A 73-year-old male diabetic patient presented at our department because of the appearance
of nonhealing ulcers at the first finger of the right foot, 20 months after right
common femoral artery (CFA) thromboendarterectomy, resulting in surgical transection
and ligation of the first segment of the superficial femoral artery (SFA). The transcutaneous
oxygen pressure (TCPO2 ) at ulcer site was 10 mm Hg.
The following computed tomography (CT) angiography examination showed regular patency
of the right CFA, SFA occlusion at its proximal third, which was the site of extensive
calcifications, and patency restoration at the Hunter channel (occlusion length: 34
cm). Popliteal artery, tibioperoneal trunk, posterior tibial, and plantar arteries
were patent, while the proximal third of the anterior tibial and peroneal arteries
resulted in occlusion. The patient had severe comorbidities, such as obesity and chronic
obstructive pulmonary disease with chronic respiratory insufficiency.
The procedure was performed after a 7-day double-antiplatelet therapy (acetylsalicylic
acid 100 mg and clopidogrel 75 mg/die). Before the procedure, the patient signed an
informed written consent.
Digital subtracted angiography, after antegrade right CFA access, confirmed CT findings
([Fig. 1A ]
[B ]). Soon after sheath insertion, low-weight heparin was systemically administered
(2,500 IU/h). Multiple attempts were made to cross the occlusion using a straight-tip
0.035” stiff guidewire (Radifocus Terumo), with the support of a 4F vertebral catheter
(Cordis), but result was unsuccessful, due to unengageable occlusion of the proximal
SFA.
Fig. 1 (A, B ) First angiograms show occlusion of the superficial femoral artery (SFA ) with rehabilitation at the level of the popliteal artery. The whole artery is site
of extensive calcifications. (C, D ) The SFA is retrogradely punctured at its proximal third, in the occluded segment,
using the calcifications as a marker. A looped wire is pushed in the subintimal space
along the occluded vessel. (E ) After exchanging the 0.035” guidewire with a 0.014” one, the Pioneer device is delivered
in the subintimal space and adjusted to reach the minimal distance between the needle
tip and the true lumen. Then, intraluminal re-entry is accomplished under intravascular
ultrasound guidance and the 0.014” wire snared from the tip of the antegrade sheath.
Using the arterial calcifications as a landmark, the occluded SFA was punctured under
fluoroscopic guidance with an 18G Seldinger needle at its proximal third, 3 to 4 cm
below the occlusion ([Fig. 1C ]). Then, a 0.035” stiff guidewire and a 6Fr long introducer sheath (Radifocus Terumo)
were retrogradely advanced in the subintimal space until reaching the SFA origin ([Fig. 1D ]), to safeguard the Pioneer device, and the wire was switched to a 0.014” one (Pilot
200) to allow its delivery.
Thus, the 6F Pioneer Plus catheter (Volcano Therapeutics) was retrogradely advanced
over the Pilot wire and its position and rotation were adjusted under combined intravascular
ultrasound and fluoroscopic guidance. The true arterial lumen at the level of CFA
bifurcation was successfully punctured ([Fig. 1E ]).
The subintimal channel was predilated using a 4 × 120 mm balloon catheter (Amphirion
Deep, Invatec) ([Fig. 2A ]), except the re-entry site, and the 6F Pioneer was antegradely advanced until reaching
the popliteal artery ([Fig. 2B ]). Once gained both intraluminal connections, the whole subintimal channel was dilated,
from distal to proximal, using a 5 × 150 mm mono-rail balloon catheter (Senri, Terumo)
([Fig. 2C ]). A 6 × 20 mm balloon-expandable covered stent (Begraft, Bentley) was deployed across
the surgical ligation site. Final angiography showed regular stent and SFA patency
and caliber ([Fig. 3A ]
[B ]).
Fig. 2 (A ) Subintimal space is predilated and the wire is driven to the level of the popliteal
artery. (B ) The Pioneer catheter is used again, this time in antegrade fashion, to gain intraluminal
re-entry at the level of the distal patent artery. (C ) The occluded segment is dilated with a 4 × 120 mm balloon-catheter from distal to
proximal.
Fig. 3 (A ) A balloon-expandable covered stent is deployed in the proximal superficial femoral
artery (SFA), across the site of the surgical ligation. (B ) Control angiography shows SFA and stent patency and restored SFA caliber.
At the 3-month follow-up visit, the patient presented a healed ulcer and increased
TCPO2 (58 mm Hg). Arterial flow was further detectable through Doppler imaging.
Discussion
Several reviews show the advantages of using re-entry devices when treating complex
iliac or femoral chronic total occlusions, in terms of enhanced technical success
and safety of revascularization procedures, decreased dissection risk by precise re-entry,
and reduced operative time and fluoroscopic exposure.[3 ]
[4 ]
In this case, we opted for puncturing the SFA in the occluded segment. The arterial
calcifications drove the puncture, giving access to the subintimal plane. The proximal
third of the SFA was chosen to minimize the pathway to the re-entry point and to improve
the system pushability in the subintimal space. Moreover, we introduced the Pioneer
catheter inside the sheath previously placed in the subintimal space, to facilitate
its delivery in the occluded arterial segment.
We performed the retrograde SFA puncture under both intravascular ultrasound (IVUS)
and fluoroscopic guidance to choose the minimal distance between the subintimal space
and the true lumen. The aim obviously was to make an effective intraluminal puncture
and, as a result, to reduce the risk of arterial rupture by the following angioplasty.
The first subintimal percutaneous transluminal angioplasty was performed to create
an appropriate channel for advancing the Pioneer catheter, but the proximal re-entry
site was not dilated at first, because without a distal re-entry, it would expose
the artery to the risk of rupture. Once obtained distal re-entry, the subintimal channel
was dilated from distal to proximal except for the proximal re-entry site.
Considering the high risk of bleeding, after this maneuver, we deployed a short balloon-expandable
covered stent across the proximal, previously ligated, re-entry site, thus creating
a sort of endovascular bypass over a suspended arterial segment and thus completing the angioplasty of the occluded
segment.
Conclusion
The revascularization of an occluded artery can be efficiently accomplished by a combined
retrograde and antegrade use of the Pioneer IVUS-guided re-entry device, even in case
of a surgically ligated artery.
