Transdistal Bypass and Collateral Approach for Infrapopliteal Chronic Total Occlusion Intervention

JACC: CARDIOVASCULAR INTERVENTIONS

VOL. 9, NO. 9, 2016

ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 1936-8798/$36.00

PUBLISHED BY ELSEVIER

http://dx.doi.org/10.1016/j.jcin.2016.01.043

IMAGES IN INTERVENTION

Transdistal Bypass and Collateral Approach for Infrapopliteal Chronic Total Occlusion Intervention Keiko Shimamoto, MD, Osami Kawarada, MD, PHD, Koichiro Harada, MD, PHD, Teruo Noguchi, MD, PHD, Hisao Ogawa, MD, PHD, Satoshi Yasuda, MD, PHD

T

he retrograde approach was first used for

peroneal artery (Figure 1C). We decided to recanalize

coronary chronic total occlusions (CTOs)

the CTO in the peroneal artery using a retrograde

with saphenous vein grafts (1). Recently,

collateral vessels have become access points for the

approach via the distal bypass–PTA collateral vessel to improve blood flow to the foot.

retrograde approach in CTO intervention, in the pe-

Retrograde advancement of a 0.014-inch hydro-

riphery as well as in the coronary artery (2,3). The com-

philic guidewire supported by a microcatheter and

bination of a saphenous vein graft and a collateral

the CART (controlled antegrade and retrograde

vessel might increase the performance of the retro-

tracking) technique facilitated subsequent antegrade crossing and balloon dilation (Figure 2). The final

grade approach. An ischemic ulcer on the left second toe developed

angiography demonstrated establishment of straight-

in an 82-year-old diabetic man on hemodialysis with a

line flow in the peroneal artery (Figure 3). The skin

history of a redo distal bypass for total occlusions in

perfusion pressure in the left foot increased from 20

the crural arteries. At another hospital, diagnostic

to 44 mm Hg, suggesting a high likelihood of wound

angiography revealed total occlusion of the common

healing (4).

plantar artery despite a patent distal bypass. When an

The combination of a saphenous vein graft and a

attempt to recanalize the occlusion in the common

collateral vessel could provide a novel retrograde

plantar artery was unsuccessful, the patient was

approach for the treatment of infrapopliteal CTOs in

referred to our hospital for further consideration of

patients with a history of distal bypass.

endovascular therapy. Our angiography identified a collateral vessel from the posterior tibial artery (PTA),

REPRINT REQUEST AND CORRESPONDENCE: Dr.

distal to the bypass, to the distal peroneal artery

Osami

(Figures 1A and 1B). Selective injection of contrast

Medicine,

from

Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565,

a

microcatheter

in

the

collateral

vessel

confirmed that the distal end of the CTO was in the

Kawarada, National

Department Cerebral

of

Cardiovascular

and

Cardiovascular

Japan. E-mail: [email protected].

From the Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received January 25, 2016; accepted January 29, 2016.

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Retrograde Transcollateral Approach With Distal Bypass

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F I G U R E 1 Pre-Interventional Angiography

(A) Diagnostic angiography revealed that the saphenous vein graft was patent between the distal popliteal artery and distal posterior tibial artery (arrowheads), but its outflow was occluded at the common plantar artery (arrows). The small arrow indicates the proximal anastomosis of the distal bypass, and the large arrows indicate the distal anastomosis of the distal bypass. Except for the tibioperoneal trunk, the anterior and posterior tibial arteries and peroneal artery were all occluded, and other vessels below the ankle were not well visualized. (B) A magnified image of the area around the ankle revealed reconstitution in the distal part of the peroneal artery (large arrows) with collateral flow (small arrows) that was linked to the posterior tibial artery above the ankle. (C) Selective injection of contrast from the microcatheter tip in the collateral vessel (arrowhead) confirmed that the distal end of the total occlusion was in the peroneal artery (longer arrow). Small arrows ¼ collateral vessel; large arrows ¼ reconstituted peroneal artery.

JACC: CARDIOVASCULAR INTERVENTIONS VOL. 9, NO. 9, 2016 MAY 9, 2016:e87–90

Shimamoto et al. Retrograde Transcollateral Approach With Distal Bypass

F I G U R E 2 Endovascular Procedures

(A) Retrograde wiring of the peroneal artery supported by a microcatheter (arrow) through the distal bypass and the collateral vessel. (B) Retrograde balloon dilation using the controlled antegrade and retrograde tracking (CART) technique. (C) Successful antegrade crossing and antegrade balloon dilation after the CART technique.

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Retrograde Transcollateral Approach With Distal Bypass

F I G U R E 3 Post-Interventional Angiography

Final angiography revealed successful recanalization of the peroneal artery.

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Cardiovasc Interv 2015 Nov 30 [E-pub ahead of print].

valuable in the diagnosis of critical limb ischemia. J Vasc Surg 1997;26:629–37.

3. Kawarada O, Sakamoto S, Harada K, Ishihara M, Yasuda S, Ogawa H. Contemporary crossing techniques for infrapopliteal chronic total occlusions. J Endovasc Ther 2014;21:266–80. 4. Castronuovo JJ Jr., Adera HM, Smiell JM, Price RM. Skin perfusion pressure measurement is

KEY WORDS CART, chronic total occlusion, collateral vessel, distal bypass, retrograde approach