Author + information
- Yasuhiro Takahashi1,
- Reiko Shiomura1,
- Erito Furuse1,
- Junya Matsuda1,
- Taisuke Sato1 and
- Wataru Shimizu2
Patient initials or identifier number
Relevant clinical history and physical exam
A 79 year-old man with a history of diabetes mellitus and dyslipidemia presented to our hospital with claudication. Magnetic resonance imaging previously performed at another hospital revealed severe stenosis of his bilateral external iliac arteries (EIAs) and chronic total occlusion (CTO) of his bilateral superficial femoral arteries (SFAs). He successfully underwent endovascular treatment (EVT) of both EIAs and the right SFA, and then readmitted to our hospital for EVT of the left SFA.
Relevant test results prior to catheterization
Ankle brachial index measured 0.53 at rest. Serum creatinine levels and e-GFR measured 0.79 mg/dl and 76.5 ml/min, respectively.
Relevant catheterization findings
Angiography of thel eft lower extremity revealed a long segment of CTO of the left SFA without a stump (Image 1).
Procedural step. Antegrade approach using aside-hole sheath and trans venous intravascular ultrasound (IVUS) was performed. The side-hole sheath features a tapered tip and a side hole, which is 7 cm from the tip. The side-hole has a 0.036-inch diameter lumen,which allows passage of a micro catheter. A guide-wire was crossed through the side-hole. Transvenous IVUS images of the target artery were obtained by an IVUS catheter placed in the vein adjacent to the target artery. The side-hole sheath introduced into the common femoral artery and the tip of the side-hole sheath was then inserted into the deep femoral artery (DFA). A Chevalier 30-g guide wire was advanced in an antegrade fashion and was observed by transvenous IVUS in the subintimal area at the middle occlusive site. The antegrade approach was then switched to a retrograde approach using a collateral channel through the DFA. A Cruise guide wire supported by a prominent standard catheter was inserted into the DFA through the tip of the side-hole sheath and was then successfully passed through a collateral channel (Image 2, 3). The Halberd guide wire was advanced in a retrograde fashion to the middle occlusive lesion. Rendezvous technique was performed by fluoroscopy and transvenous IVUS after advancement of the antegrade guide wire to the intimal area near the retrograde guide wire. After balloon angioplasty, final angiography revealed optimal recanalization. (Image 4)
The retrograde guide wire supported by the micro catheter was easily inserted into the DFA via the tip of the side-hole sheath and then successfully passed through a collateral channel. A side-hole sheath was very useful in the treatment of CTO of the SFA using a transcollateral approach.