K.E.M. Radiology
Patients First!
Welcome to the Academic and Educational pages of the
Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Retrograde approach for revascularization of challenging a chronic total occlusion.
Contributed by:
Contributed by : Amruta Varma
Introduction:
Antegrade approaches to arterial recanalisation can be performed using true lumen or subintimal technique. A re-entry device can be used to cross the occlusion in case of subintimal passage of a wire. But these devices are not always available and are expensive. Hence an alternative approach (i.e. retrograde approach) is used , allowing for better treatment option for these complex lesions. The first retrograde approach was described by Iyer et al. [3]. This promising technique had good results and was performed through surgical incision and direct arterial puncture . This technique requires training and has a learning curve. So it was used in difficult cases in which antegrade approaches fail.
Case presentation:
A 69 year old man presented with complaints of pain in the right lower limb on rest since two months. The patient had blackish discoloration and a non healing ulcer on the lateral aspect of the 5th toe. (Fig. 1)
Fig. 1 : Blackish discoloration, non healing ulcer on the lateral aspect of the 5th toe.
The ankle brachial index on right was 0.39 and on left was 0.92. CT angiography showed a long segment occlusion of the proximal and middle superficial femoral artery (SFA) , with reformation through collaterals in the distal SFA.. These findings were confirmed on the catheter angiogram. (Video 1a). There was occlusion of the proximal anterior tibial artery (ATA) with reformation of mid and distal ATA (VIDEO 1b)
Interventional Technique:
Through a left femoral access using 18 G introducer needle and a 7F crossover balkin sheath (Cook, Bloomington, Indiana, USA ) placed in the contralateral right External iliac artery, multiple attempts were made to to cross / reenter the distal lumen. These were however not successful. Attempts were made to re-enter the true lumen using the outback device ( Fig. 2). These too were not successful.
Under ultrasonographic and fluoroscopic guidance, a retrograde approach was then opted for. The distal right SFA was accessed (Fig. 3) . A V18 guidewire was negotiated through the the occlusion in the retrograde manner and was snared through Balkin via the previous contralateral puncture. (Video 2)
Fig. 2: Attempts were made to re-enter the true lumen using the outback device.
Fig 3 : Retrograde approach was then opt for, with the puncture in the right distal SFA
Video 2: Snaring of the V18 wire through Balkin via the previous contralateral puncture.
Prediltation of the occluded lesion in the SFA was done using a 2.5x 100mm peripheral balloon at 8-10 atm, for the passage of the catheter. Following pre-dilatation, 0.014” Nitrex wire was passed along with a 4f Headhunter 1 catheter antegradely across the lesion, into the popliteal artery. The puncture site was sealed off by removing the v-18 from the distal retrograde puncture site (Video 3) , with simultaneous inflation of a 5 x 40 mm balloon for a span of 10 minutes , over the 0.014 nitrex at the site of puncture.( Fig. 4) , A check angiogram was performed o rule out extravasation from that puncture site. puncture (Video 4)
Video 3 : Puncture site sealed off by removing v-18 from the distal retrograde puncture site with simultaneous inflation of the balloon.
Fig. 4 : Simultaneous inflation of a 5 x 40 mm balloon for over a span of 10 minutes, over the 0.014 Nitrex at the site of puncture.
Video 4: Check run to confirm absence of extravasation / hematoma at the site of puncture.
Over the nitrex wire, two 6 x170 mm self-expandable stents (Image 5), were passed with the the second one overlapping the first. Post stent plasty (Fig. 6) was performed using a 6 x 120 mm balloon.
Fig. 5
Fig. 6
Fig. 5: 6 x170 mm self-expandable deployed in proximal and mid SFA.
Fig. 6: Post stenting plasty using 6 x 120 mm balloon.
Post stenting angiogram was showed a widely patent stented segment of recanalized SFA throughout its course. (Video 5). The infra popliteal angiogram with tip of Progreat microcatheter in the popliteal artery showed fresh occlusion of the proximal ATA origin (Video 6) just after its origin. Using a retrograde puncture in the distal ATA, (Image 7) , aV-18 guide wire was negotiated through the occluded proximal ATA and was snared via the contralateral puncture. A 0.014” nitrex wire was passed from the contralateral side through the Progreat microcatheter, with tip of nitrex in DPA.
Video 5: Post stenting plasty angiogram was suggestive of widely patent stented segment of recanalized SFA with antegrade flow.
Video 6: Infra popliteal angiogram suggestive of flush occlusion of the proximal ATA origin.
Fig. 7: V-18 guide wire was negotiated through the occluded proximal ATA and was snared via the contralateral puncture.
Angioplasty of the occluded proximal ATA and distal popliteal artery was performed using a 3x 40 mm balloon. (Image 8) Post plasty angiogram showed normal opacification of the anterior tibial artery (Video 7).
Fig. 8: Angioplasty was done of the occluded proximal ATA and distal Popliteal artery.
VIdeo 7: Post plasty angiogram revealed normal opacification of the Anterior tibial artery.
After the procedure, dual antiplatelet (aspirin (150 mg/day) and cilostazol (100 mg twice/day)) were advised for three months and then lifelong daily aspirin thereafter. At six weeks post procedure, the ulcer was found to have healed. (Fig. 9)
Fig. 9
Fig 9: 6 weeks follow up of the patient revealed healed ulcer.