Author + information
- Reiko Shiomura1,
- Yasuhiro Takahashi1,
- Erito Furuse1,
- Junya Matsuda1,
- Taisuke Sato1 and
- Wataru Shimizu2
Patient initials or identifier number
Relevant clinical history and physical exam
A 75 year-old man with diabetes mellitus, hypertension, and chronic kidney disease on maintenance hemodialysis, who had undergone coronary artery bypass surgery for myocardial infarction, had right foot pain and ulceration. He was diagnosed with critical limb ischemia.
Relevant test results prior to catheterization
Ankle brachial index on the left was 0.59. Enhanced computed tomography revealed chronic total occlusion of the superficial femoral artery (SFA).
Relevant catheterization findings
Angiography showed chronic totalocclusion (CTO) of the left SFA (Image 1).
A side-hole sheath was introduced through the right common femoral artery (CFA) using an antegrade approach, and the tip of the sheath was inserted into the right deep femoral artery (DFA). The side-hole sheath features a tapered tip and a side hole,which is 7 cm from the tip. A guide wire crossed the lesion of the SFA through the side hole, and catheter systems that are adaptable to a 6-Fr sheath introducer were passed through the side hole. A 0.035-inch Radifocus 1.5-J guide wire supported by an Elite Cross support catheter with an angled tip was easily advanced into the CTO of the SFA through the side hole at the distal non-occluded site. However, the guidewire was inserted into the false lumen. Therefore, an Outback® Elite catheter inserted into the distal false lumen using a 0.014-inch Chevalier Universal guide wire. Following angiography of the distal true lumen through the tip inserted into the DFA of the side-hole sheath, the cannula of the Outback® Elite catheter was passed from the false lumen to the true lumen under fluoroscopic guidance (Image 2, 3). Two self-expandable stents were deployed after predilation by using a percutaneous transluminal angioplasty balloon. Final angiography showed optimal recanalization (Image 4).
In deployment of the cannula of a reentry catheter towards the true lumen in the antegrade approach to SFA CTO, a conventional sheath that is inserted into the occluded segment during guidewire crossing of the lesion is retracted to the CFA to inject contrast medium intothe DFA, from which blood flow to the distal true lumen is supplied. This approach was very effective, because optimal angiography of the distal true lumen achieved through the tip of the side-hole sheath, which was positioned at the DFA.