Hayakawa Naoki, Miwa Hiromi, Tsuchida Yasuyuki, Ichihara Shinya, Maruta Shunsuke, Kushida Shunichi
Department of Cardiovascular Medicine, Asahi General Hospital, I-1326 Asahi, Chiba, 289-2511, Japan.
CVIR Endovasc. 2024 Dec 7;7(1):85. doi: 10.1186/s42155-024-00503-0.
Endovascular therapy is an effective method for revascularization in lower extremity artery disease, but treating chronic total occlusion (CTO) remains challenging. This is particularly true for patients with severe calcification, poor run-off in below-the-knee arteries, or limited access sites, where even guidewire (GW) passage can be difficult and bidirectional approaches are often not feasible. The tip-detection (TD) method has been reported as a useful technique in coronary artery CTO interventions, allowing real-time visualization of the GW tip direction. Here, we applied the TD technique for peripheral CTO intervention.
Case 1 involved a 71-year-old man with a right toe ulcer. Angiography revealed total occlusion from the right anterior tibial artery (ATA) to the proximal dorsalis pedis artery. While attempting IVUS-guided parallel wiring, the GW could not advance through the intraplaque route because of severe calcification. We intentionally advanced the GW and IVUS into the subintimal space of the ATA to bypass the calcified lesion and performed IVUS-guided reentry using the TD technique in the distal ATA, where calcification was less severe. The second GW successfully passed through the intraplaque of the distal ATA and into the true lumen of the dorsalis pedis artery. Case 2 involved a 60-year-old man with bilateral intermittent claudication. Angiography revealed severe stenosis of the right common iliac artery (CIA) and CTO of the left CIA. Because of anatomical limitations and access site challenges, the antegrade approach for the left CIA was unsuccessful, and retrograde intraluminal wiring was difficult because of flexion and calcification. We advanced the GW and IVUS into the subintimal space and performed IVUS-guided reentry using the TD technique to access the true lumen of the proximal CIA. Finally, bilateral VBX stent grafts were implanted using the kissing stent technique.
IVUS-guided reentry wiring with the TD technique may offer a useful solution for passing complex peripheral CTO lesions in cases where only a uni-directional approach is feasible.
血管内治疗是下肢动脉疾病血运重建的有效方法，但治疗慢性完全闭塞（CTO）仍然具有挑战性。对于严重钙化、膝下动脉流出道不佳或入路部位有限的患者尤其如此，在这些情况下，即使导丝（GW）通过也可能困难，双向入路通常不可行。尖端检测（TD）方法已被报道为冠状动脉CTO介入治疗中的一种有用技术，可实时显示GW尖端方向。在此，我们将TD技术应用于外周CTO介入治疗。
病例1为一名71岁男性，患有右脚趾溃疡。血管造影显示从右胫前动脉（ATA）到足背动脉近端完全闭塞。在尝试血管内超声（IVUS）引导下的平行布线时，由于严重钙化，GW无法通过斑块内路径推进。我们故意将GW和IVUS推进到ATA的内膜下间隙以绕过钙化病变，并在钙化较轻的远端ATA中使用TD技术进行IVUS引导下的重新进入。第二根GW成功穿过远端ATA的斑块内并进入足背动脉的真腔。病例2为一名60岁男性，患有双侧间歇性跛行。血管造影显示右髂总动脉（CIA）严重狭窄和左CIA慢性完全闭塞。由于解剖学限制和入路部位挑战，左CIA的顺行入路未成功，并且由于弯曲和钙化，逆行腔内布线困难。我们将GW和IVUS推进到内膜下间隙，并使用TD技术进行IVUS引导下的重新进入以进入近端CIA的真腔。最后，使用吻合法支架技术植入双侧VBX支架移植物。
在仅单向入路可行的情况下，IVUS引导下使用TD技术重新进入布线可能为通过复杂的外周CTO病变提供一种有用的解决方案。
