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Relevant clinical history and physical exam
The case showed an 80 year-old man with intermittent claudication admitted to our hospital (Fontaine II, Rutherford I-3). Diagnostic angiography revealed his right superficial femoral artery (SFA) - CTO lesion (TASC D lesion) and we performed EVT. He had an intermediate renal failure.
Relevant test results prior to catheterization
A CTA showed a bilateral long SFA-CTO lesions. Doppler echo test for both lower limb showed several intermediate stenoses in SFA. The resting ankle brachial index (ABI) score of his both leg revealed less than 0.90.
Relevant catheterization findings
We initially attempted EVT using left femoral artery puncture approach with ante grade and use carbon dioxide in substitution for contrast media, because he had an intermediate renal failure.
We initially attempted EVT using left femoral artery puncture approach with ante grade and use carbon dioxide in substitution for contrast media, because he had an intermediate renal failure. A 6-Fr parent guide catheter inserted into the left femoral artery. 5.5Fr catheter was used for back up catheter.Initial angiography revealed mid- SFA CTO lesion. Firstly, Cruise guide wire advanced under IVUS, but could not penetrate, because lesion has a severe calcs. Therefore, we changed the guide wire to Astato 9-12, and Astato 8-40. An Astato 8-40 wire with IVUS was advanced but was entered into subintimal space angiographically. A SFA lesion could not be crossed with ante grade approach alone and a retrograde approach from distal of SFA was, therefore, added. We secondary attempted bi-directional procedure using SFA distal puncture approach for performing rendezvous technique. However, it is difficult to control the wire exactly. In this situation, a site where the wire can enter should be found by trial and error. To catch an exit exactly, 3D wiring technique used and we succeed in rendezvous technique with 3D wiring technique. After crossing the wire, we performed balloon dilation and stent implantation for the lesion.
We report a novel interventional technique, a three-dimensional guide wire technique(3D-wiring), to improve the initial success rate of EVT for long SFA-CTO lesions. We present one representative case, and describe the technical tips and appropriate device selection criteria for the 3D-wiring procedure.