Miyashita Hirokazu, Tobita Kazuki, Uchida Syuhei, Koyama Eiji, Tamaki Yusuke, Yamashita Takayoshi, Saito Shigeru
Department of Cardiology, Heart Center, Shonan Kamakura General Hospital, Okamoto 1370-1, 2478533, Kamakura, Japan.
CVIR Endovasc. 2023 Jun 22;6(1):34. doi: 10.1186/s42155-023-00380-z.
Although majority of cases with chronic total occlusion (CTO) in femoro-popliteal lesion were treated with antegrade approach only, some lesions require alternative approach due to its complexity. Bi-directional approach is useful on endovascular therapy (EVT) for CTO; however guidewire passage through the lesion is impossible in some challenging cases. The present case shows a successful re-entry technique utilizing two snare catheters from an antegrade and retrograde access site (double snare piecing technique).
A 79-year-old woman with right leg intermittent claudication (Rutherford category IV), who had undergone unsuccessful EVT for popliteal CTO, required another EVT for the worsening symptom. Following the failed conventional crossing technique (wire knuckle technique, intravascular-ultrasound-guided wiring, and controlled antegrade and retrograde subintimal tracking technique), two snare catheters were placed and the snare loops were pierced by a puncture needle percutaneously. After an 0.014 wire was inserted into the needle, the needle was withdrawn. The wire was pulled from the retrograde side and was externalized. Then, the antegrade snare catheter was pulled and externalized, to make the wire across the lesion. After that, a microcatheter was advanced along the externalized wire from the retrograde side and cross the lesion. The wire was replaced with a new wire, which completely created pull-through system. After the hemostasis by balloon inflation and lesion preparation, this procedure was completed with an endoluminal-covered stent and two inter-woven stents. The re-entry site was covered by the inter-woven stent. Her symptoms improved after the procedure, and the lesion has not developed restenosis at 2-years follow-up.
This re-entry technique of puncturing two snare loops (double snare piercing technique) might be effective for achieving successful passage through challenging femoropopliteal CTO cases.
尽管股腘病变慢性完全闭塞（CTO）的大多数病例仅采用顺行入路治疗，但由于病变复杂，一些病例需要采用替代入路。双向入路在CTO的血管内治疗（EVT）中很有用；然而，在一些具有挑战性的病例中，导丝无法穿过病变。本病例展示了一种利用来自顺行和逆行入路部位的两个圈套器导管的成功再入技术（双圈套穿刺技术）。
一名79岁女性，右下肢间歇性跛行（卢瑟福分级IV级），腘动脉CTO的EVT治疗失败，因症状加重需要再次进行EVT。在传统的穿越技术（导丝成袢技术、血管内超声引导下导丝置入以及可控顺行和逆行内膜下寻迹技术）失败后，放置了两个圈套器导管，并用穿刺针经皮穿刺圈套器环。将一根0.014英寸的导丝插入针内后，拔出针。将导丝从逆行侧拉出并引出体外。然后，将顺行圈套器导管拉出并引出体外，使导丝穿过病变。之后，沿从逆行侧引出体外的导丝推进微导管并穿过病变。用一根新导丝替换原来的导丝，从而完全建立了通过系统。通过球囊扩张止血并准备病变后，该手术通过腔内覆膜支架和两个交织支架完成。再入部位由交织支架覆盖。术后她的症状有所改善，在2年的随访中病变未出现再狭窄。
这种穿刺两个圈套器环的再入技术（双圈套穿刺技术）可能对成功通过具有挑战性的股腘CTO病例有效。
