Author + information
- Naoki Hayakawa1
Patient initials or identifier number
Relevant clinical history and physical exam
An 85 year old male was referred for intermittent claudication of his left lower limb.He wanted to treat because the symptom was progressing.His left femoral artery was palpable, but his popliteal artery and tibial arteries was not palpable.
Relevant test results prior to catheterization
His ankle brachial index was right: 0.91, left: 0.53.MRA showed total occlusion from its middle part of left superficial femoralartery (SFA).
Relevant catheterization findings
We performed right femoral puncture because we wantedto evaluate his right lower limb and his coronary arteries at the same time.Control angiography showed a total occlusion in the left SFA from mid toproximal part of pop artery. A 6Fr Destination ®guiding sheath was inserted incontralateral retrograde fashion into the right common femoral artery.
Using Halberd® wire with a Rubicon® microcatheter, we performed antegrade wiring. However the distal site of CTO was very hard, antegrade wiring was in distress. Then we converted to retrograde approach withdorsalis artery puncture. Retrograde Command® wire advanced into antegradeRubcon® byrendez-vous technique and pull through was done. Then we checked IVUS, the wire was in subintimal false, so we tried rewiring. First we triedantegrade IVUS guided wiring, we could advance into intimal true with AstatoXS 9-40®, but we could not pass into distal true lumen. Retrograde Naveed4Hard30g® wirewas advanced into plaque, but could not advance into antegrade true lumen. Wechecked IVUS again, and IVUS showed both wire came close only a part of distalSFA. So we performed the rendez-vous technique at that point while looking byIVUS. After that we could dilate the lesion with small noncompliant balloonwith high pressure again and again. IVUS showed there was thicked fibrousplaque in his distal SFA. We dilated all part of the lesion by Coyote®4.0×150mmballoon. The SMART control®stents 6.0×150mm was implanted tocover the entire lesion. Final angiography showed appropriate expansion ofstented segment and sufficient blood flow to the left lower extremity.
After that procedure,ankle-brachial index increased to 0.90 from 0.53, and the symptom ofclaudication was improved. We think the key point of this case was that wechecked rendez-vous point by IVUS. We experienced a tough case andsucceeded to recanalise all true lumen of SFA CTO by very complicatedprocedure.