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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Retrograde approach for revascularization of challenging a chronic total occlusion.
Retrograde approach for revascularization of challenging a chronic total occlusion.
Contributed by:
Contributed by:
Contributed by : Amruta Varma
Contributed by : Amruta Varma
Introduction:
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.
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:
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)
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)
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:
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.
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)
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)
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.
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.
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).
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)
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.
Discussion:
Discussion:
In cases of failed antegrade technique, an attempt from retrograde approach should be done. The rationale behind the retrograde approach is:- The proximal fibrous cap is usually thicker and harder than the distal cap [4]. Furthermore, the distal fibrous cap is typically tapered, therefore when the operator views it from the proximal side it looks like a convex shape. This feature, especially if calcium and fibrous tissue are present at the location, can cause wires problems when they are pushed anterogradely, as they are redirected into the subintimal space. The proximal and distal cap characteristics are the main reason why the retrograde approach has been developed and has gained successful application in percutaneous CTO recanalization. Many techniques have been used to facilitate the negotiation of the guide wire through the true lumen using a true lumen technique, sub-intimal technique or a retrograde approach.
In cases of failed antegrade technique, an attempt from retrograde approach should be done. The rationale behind the retrograde approach is:- The proximal fibrous cap is usually thicker and harder than the distal cap [4]. Furthermore, the distal fibrous cap is typically tapered, therefore when the operator views it from the proximal side it looks like a convex shape. This feature, especially if calcium and fibrous tissue are present at the location, can cause wires problems when they are pushed anterogradely, as they are redirected into the subintimal space. The proximal and distal cap characteristics are the main reason why the retrograde approach has been developed and has gained successful application in percutaneous CTO recanalization. Many techniques have been used to facilitate the negotiation of the guide wire through the true lumen using a true lumen technique, sub-intimal technique or a retrograde approach.
Approach to chronic occlusion techniques
Approach to chronic occlusion techniques
True lumen technique
True lumen technique
Using conventional wire and catheter , few true lumen crossing devices are also available
Using conventional wire and catheter , few true lumen crossing devices are also available
Subintimal technique:
Subintimal technique:
The subintimal approach may be used after unsuccessful attempts using conventional wire and catheter techniques. Subintimal access may be achieved using a 4- or 5F angled-tip catheter directed at the vessel wall at the level of the occlusion. An angled hydrophilic guidewire is then used to enter the subintimal plane. Careful fluoroscopic visualization of the guidewire loop will show the wire freely traversing the occlusion with minimal resistance. Spontaneous reentry to the true lumen will occur in a majority of cases with little to no guidewire or catheter manipulation. A reentry device may be used to facilitate guidewire passage to the true lumen. Alternate devices use balloon assistance with a flat or conically shaped balloon that self-orients in the subintimal space and an angled reentry probe.
The subintimal approach may be used after unsuccessful attempts using conventional wire and catheter techniques. Subintimal access may be achieved using a 4- or 5F angled-tip catheter directed at the vessel wall at the level of the occlusion. An angled hydrophilic guidewire is then used to enter the subintimal plane. Careful fluoroscopic visualization of the guidewire loop will show the wire freely traversing the occlusion with minimal resistance. Spontaneous reentry to the true lumen will occur in a majority of cases with little to no guidewire or catheter manipulation. A reentry device may be used to facilitate guidewire passage to the true lumen. Alternate devices use balloon assistance with a flat or conically shaped balloon that self-orients in the subintimal space and an angled reentry probe.
Safari :
Safari :
Subintimal arterial flossing with antegrade and retrograde intervention (SAFARI) may be used when advanced reentry techniques fail
Subintimal arterial flossing with antegrade and retrograde intervention (SAFARI) may be used when advanced reentry techniques fail
Often times, the occlusion may be crossed through the retrograde access while staying true lumen. However, subintimal recanalization from the retrograde access is frequently required. After the retrograde wire has crossed the occlusion and is within the proximal vessel, the wire may be snared from the antegrade access. The wire is then pulled through the antegrade sheath for through-and-through access.
Often times, the occlusion may be crossed through the retrograde access while staying true lumen. However, subintimal recanalization from the retrograde access is frequently required. After the retrograde wire has crossed the occlusion and is within the proximal vessel, the wire may be snared from the antegrade access. The wire is then pulled through the antegrade sheath for through-and-through access.
Reverse cart:
Reverse cart:
Reverse CART (controlled antegrade and retrograde subintimal tracking ) frequently the retrograde and antegrade accesses, while both within the subintimal space, do not communicate. A 4-mm angioplasty balloon may be advanced over the antegrade access and inflated within the subintimal plane. This can disrupt the intimal layers prohibiting communication between antegrade and retrograde access.
Reverse CART (controlled antegrade and retrograde subintimal tracking ) frequently the retrograde and antegrade accesses, while both within the subintimal space, do not communicate. A 4-mm angioplasty balloon may be advanced over the antegrade access and inflated within the subintimal plane. This can disrupt the intimal layers prohibiting communication between antegrade and retrograde access.
Techniques of retrograde approaches
Techniques of retrograde approaches
a) Pedal-plantar loop technique which involves the passage of a wire from the Anterior tibial artery (ATA) to Posterior tibial artery (PTA) (or vice versa) through the pedal arch of the foot.
a) Pedal-plantar loop technique which involves the passage of a wire from the Anterior tibial artery (ATA) to Posterior tibial artery (PTA) (or vice versa) through the pedal arch of the foot.
b) The second is the trans collateral approach which uses a collateral artery suitable for guide wire passage to recanalize the tibials or foot arteries
b) The second is the trans collateral approach which uses a collateral artery suitable for guide wire passage to recanalize the tibials or foot arteries
c) Retrograde percutaneous access which is done by direct puncture of a distal patent artery followed by passage of the wire in a retrograde direction then dilatation of the CTO followed by the standard antegrade angioplasty.
c) Retrograde percutaneous access which is done by direct puncture of a distal patent artery followed by passage of the wire in a retrograde direction then dilatation of the CTO followed by the standard antegrade angioplasty.
Retrograde approach can be used in failure of antegrade recanalization with the patient in the same supine position. Retrograde access for complex CTO disease has proven to be an easy and successful technique for treatment of patients with poor options or failed previous attempts. Interventionists should be encouraged to use this technique in their daily practices.
Retrograde approach can be used in failure of antegrade recanalization with the patient in the same supine position. Retrograde access for complex CTO disease has proven to be an easy and successful technique for treatment of patients with poor options or failed previous attempts. Interventionists should be encouraged to use this technique in their daily practices.
References:
References:
1. Graziani L, Silvestro A, Bertone V, Manara E, Andreini R, Sigala A, et al. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Vasc Endovasc Surg 2007; 33:453–460
1. Graziani L, Silvestro A, Bertone V, Manara E, Andreini R, Sigala A, et al. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Vasc Endovasc Surg 2007; 33:453–460
2. Söder HK, Manninen HI, Jaakkola P, Matsi PJ, Räsänen HT, Kaukanen E, et al. Prospective trial of infrapopliteal artery balloon angioplasty for critical limb ischemia: angiographic and clinical results. J Vasc Interv Radiol 2000; 11:1021–1031.
2. Söder HK, Manninen HI, Jaakkola P, Matsi PJ, Räsänen HT, Kaukanen E, et al. Prospective trial of infrapopliteal artery balloon angioplasty for critical limb ischemia: angiographic and clinical results. J Vasc Interv Radiol 2000; 11:1021–1031.
3. Iyer SS, Dorros G, Zaitoun R, Lewin RF. Retrograde recanalization of an occluded posterior tibial artery by using a posterior tibial cutdown: two case reports. Cathet Cardiovasc Diagn 1990; 20:251–253
3. Iyer SS, Dorros G, Zaitoun R, Lewin RF. Retrograde recanalization of an occluded posterior tibial artery by using a posterior tibial cutdown: two case reports. Cathet Cardiovasc Diagn 1990; 20:251–253
4. Mishra S. Unraveling the mystique of CTO interventions: tips and techniques of using hardware to achieve success. Indian Heart Journal. 2017 Mar 1;69(2):266-76.
4. Mishra S. Unraveling the mystique of CTO interventions: tips and techniques of using hardware to achieve success. Indian Heart Journal. 2017 Mar 1;69(2):266-76.
5. Tummala S, Richardson AJ. Infrapopliteal artery chronic total occlusion crossing techniques: an overview for endovascular specialists. InSeminars in Interventional Radiology 2021 Oct 7 (Vol. 38, No. 04, pp. 492-499). 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA: Thieme Medical Publishers, Inc..
5. Tummala S, Richardson AJ. Infrapopliteal artery chronic total occlusion crossing techniques: an overview for endovascular specialists. InSeminars in Interventional Radiology 2021 Oct 7 (Vol. 38, No. 04, pp. 492-499). 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA: Thieme Medical Publishers, Inc..
6. Abd El-Hay T, Regal S, Farag M, Elmetwally A. Retrograde approach for complex lower limb arterial occlusions. The Egyptian Journal of Surgery. 2018 Jan 1;37(1):60-7
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