Author + information
- Hitoshi Anzai1
Patient initials or identifier number
Relevant clinical history and physical exam
She is 70 years-old female. In 2004; Diabetes was onset. In 2005; Right adrenalectomy for Cushing syndrome. In 2014; Sigmoidectomy for colon cancer. She had been treated with insulin and steroid replacement therapy.
In June 2015, she visited a plastic surgeon in our hospital for callus formation in her right plantar. In December, it recurred and plantar abscess developed. Because healing process was very delayed that she referred to cardiology department for evaluation of limbs ischemia.
Relevant test results prior to catheterization
Laboratory findings showed renal dysfunction (Cr 1.39 mg / dl) and poor blood glucose control (HbA1c 7.6 %).
ABI was 0.56/ 0.70 (R/L).The 3D CT showed no narrowing in the iliac arteries, however the right superficial femoral artery (SFA) had diffuse narrowing including total occlusion. The narrowing started at very proximal site of the right SFA and the right deep femoral artery (DFA) arose at higher position (high take off). As for below the knee artery, blood flow looked maintained.
Relevant catheterization findings
The CAG showed total occlusion in the mid LAD and the distal part of LAD filled by collateral via septal branches from RCA and ipsilateral septal branches as well.The angiography before the procedure showed almost the same findings as 3D CT. It showed the terminal aortic bifurcation angle was very shallow and the both common iliac arteries became transverse position due to elongation of the abdominal aorta.
We performed this procedure by crossover approach because the stenosis started at very proximal of the right SFA and the right DFA arose at a higher position.
1. A 4Fr sheath was inserted via the left common femoral artery (CFA)
2. We could not advance a 0.035 wire with JR4 4Fr catheter to the right iliac artery (IA) because of sharp angle of the aortic bifurcation with transverse position
3. A 6Fr guide sheath was inserted and a 0.014 support wire successfully went into the right IA. Then a Guideliner PV (Japan Lifeline) was smoothly advanced along with the 0.014 wire.
4. Despite anchor technique, it was impossible to advance the 6Fr guide sheath into the right IA (Fig 1)
5. We started guide wire manipulation with a micro catheter in this condition. The guide wire entered the CTO but failed to catch the true lumen of SFA even after stepping up tip load of wires(up to 10 g).
6. We established bi directional approach by SFA distal puncture and advanced a 0.014 wire with a micro catheter (Fig 2). The retrograde guide wire successfully reached the proximal true lumen by reverse CART technique. During this procedure, the 6Fr guide sheath happened to get into the right IA
7. The retrograde wire went into the guide sheath and externalization was established. One Misago stent (6/150 mm) was implanted to cover the CTO, followed by 5 mm balloon dilatation. The proximal SFA lesion was fixed by balloon dilatation alone. Angiography showed adequate lumen enlargement (Fig.3)
The crossover approach is a standard technique when we treat the SFA disease. However, we sometimes encounters a case that has a very shallow angle of terminal aortic bifurcation, which seems not easy to get a guide sheath into a contralateral side. In Japan, although the antegrade approach is commonly used for SFA disease, it is difficult to apply the antegrade approaching some cases; DFA high take-off or significant narrowing or occlusion at just proximal SFA. In this condition, the Guideliner PV (Japan Lifeline) is one of options to establish the crossover approach. And this can provide adequate guide wire manipulation performance even if a guide sheath is still in the ipsilateral side.