Haraguchi Takuya, Fujita Tsutomu, Kashima Yoshifumi, Tsujimoto Masanaga, Watanabe Tomohiko, Sugie Takuro, Hachinohe Daisuke, Kaneko Umihiko, Kobayashi Ken, Kanno Daitaro, Sato Katsuhiko
Director of Cardiology and Head of Peripheral Artery Disease Center, Sapporo Heart Center, North 49, East 16, 8-1, Higashi ward, Sapporo, Hokkaido, 007-0849, Japan.
CVIR Endovasc. 2021 Dec 14;4(1):87. doi: 10.1186/s42155-021-00276-w.
The successful intervention for peripheral artery disease is limited by complex chronic total occlusions (CTOs). During CTO wiring, without the use of intravascular or extravascular ultrasound, the guidewire position is unclear, except for calcified lesions showing the vessel path. To solve this problem, we propose a novel guidewire crossing with plaque modification method for complex occlusive lesions, named the "Direct tip Injection in Occlusive Lesions (DIOL)" fashion.
The "DIOL" fashion utilizes the hydraulic pressure of tip injection with a general contrast media through a microcatheter or an over-the-wire balloon catheter within CTOs. The purposes of this technique are 1) to visualize the "vessel road" of the occlusion from expanding a microchannel, subintimal, intramedial, and periadventitial space with contrast agent and 2) to modify plaques within CTO to advance CTO devices safely and easily. This technique creates dissections by hydraulic pressure. Antegrade-DIOL may create dissections which extend to and compress a distal lumen, especially in below-the-knee arteries. A gentle tip injection with smaller contrast volume (1-2 ml) should be used to confirm the tip position which is inside or outside of a vessel. On the other hand, retrograde-DIOL is used with a forceful tip injection of moderate contrast volume up to 5-ml to visualize vessel tracks and to modify the plaques to facilitate the crossing of CTO devices. Case-1 involved a severe claudicant due to right superficial femoral artery occlusion. After the conventional bidirectional subintimal procedure failed, we performed two times of retrograde-DIOL fashion, and the bidirectional subintimal planes were successfully connected. After two stents implantation, a sufficient flow was achieved without complications and restenosis for two years. Case-2 involved multiple wounds in the heel due to ischemia caused by posterior tibial arterial occlusion. After the conventional bidirectional approach failed, retrograde-DIOL was performed and retrograde guidewire successfully crossed the CTO, and direct blood flow to the wounds was obtained after balloon angioplasty. The wounds heeled four months after the procedure without reintervention.
The DIOL fashion is a useful and effective method to facilitate CTO treatment.
外周动脉疾病的成功干预受到复杂慢性完全闭塞（CTO）的限制。在CTO导丝置入过程中，若不使用血管内或血管外超声，除了钙化病变能显示血管路径外，导丝位置不明确。为解决这一问题，我们提出了一种用于复杂闭塞病变的新型导丝穿过并斑块修饰方法，即“闭塞病变直接尖端注射（DIOL）”方式。
“DIOL”方式利用通过微导管或CTO内的过线球囊导管用普通造影剂进行尖端注射的液压。该技术的目的是：1）通过用造影剂扩张微通道、内膜下、中膜内和外膜周围空间来可视化闭塞的“血管路径”；2）修饰CTO内的斑块，以安全、轻松地推进CTO器械。该技术通过液压形成夹层。顺行DIOL可能会形成延伸至并压迫远端管腔的夹层，尤其是在膝下动脉。应使用较小造影剂体积（1 - 2毫升）进行轻柔的尖端注射，以确认尖端位于血管内还是血管外。另一方面，逆行DIOL用于强力尖端注射适量造影剂，最多5毫升，以可视化血管轨迹并修饰斑块，便于CTO器械穿过。病例1为一名因右股浅动脉闭塞导致严重跛行的患者。在传统双向内膜下手术失败后，我们进行了两次逆行DIOL方式，成功连接了双向内膜下平面。植入两枚支架后，实现了充足的血流，两年内无并发症和再狭窄。病例2为一名因胫后动脉闭塞导致缺血而足跟多处伤口的患者。在传统双向方法失败后，进行了逆行DIOL，逆行导丝成功穿过CTO，球囊血管成形术后伤口获得直接血流。术后四个月伤口愈合，无需再次干预。
DIOL方式是促进CTO治疗的一种有用且有效的方法。
