Feasibility of the novel proximal superficial femoral artery puncture technique to recanalize chronic total occlusions.

Chronic total occlusion (CTO) of the superficial femoral artery (SFA) with flush occlusion is sometimes difficult to be treated by endovascular treatment (EVT). The guidewire could not pass the proximal cap because the entry of the CTO could not be detected by angiography. Thus, a retrograde approach is considered; however, there was a risk of jeopardizing the adjacent deep femoral artery by subintimal angioplasty. Moreover, the retrograde approach is not feasible when the distal artery could not be punctured because of stenosis, occlusion, or uncomfortable positioning for patients during EVT. Therefore, we considered a novel technique to overcome this problem, called the Proximal superficial femoral Artery Puncture to RecanalIze the Chronic totAl occlusion (PAPRICA) technique. In this technique, to establish wire externalization, a retrograde puncture was performed from the proximal site of the SFA-CTO under ultrasound guidance, and the guidewire was advanced retrogradely from the puncture needle via the CTO site. After wire externalization, the guide catheter could be advanced into the SFA ostium. By pulling up the externalization wire, a strong backup and improved coaxial alignment of the guide catheter were achieved. This report presents two successful cases of flush SFA-CTO using this novel technique.