- Email: [email protected]
Angioplasty of the Occluded Persistent Sciatic Artery Using the Retrograde Approach from Superficial Femoral Artery
Accepted Manuscript Angioplasty of the occluded persistent sciatic artery using the retrograde approach from superficial femoral artery Ryuta Sugihara, Yasunori Ueda, Yuji Nishimoto, Kuniaki Takahashi, Tomoaki Nakano, Yoshiharu Higuchi, Kazunori Kashiwase, Akio Hirata, Yasuharu Takeda, Yoshio Yasumura PII:
S0890-5096(17)30355-2
DOI:
10.1016/j.avsg.2016.10.053
Reference:
AVSG 3195
To appear in:
Annals of Vascular Surgery
Received Date: 19 July 2016 Revised Date:
5 October 2016
Accepted Date: 11 October 2016
Please cite this article as: Sugihara R, Ueda Y, Nishimoto Y, Takahashi K, Nakano T, Higuchi Y, Kashiwase K, Hirata A, Takeda Y, Yasumura Y, Angioplasty of the occluded persistent sciatic artery using the retrograde approach from superficial femoral artery, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.10.053. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Angioplasty of the occluded persistent sciatic artery using the retrograde approach
2
from superficial femoral artery
3 Ryuta Sugihara1, Yasunori Ueda2, Yuji Nishimoto1, Kuniaki Takahashi1, Tomoaki
5
Nakano1, Yoshiharu Higuchi1, Kazunori Kashiwase1, Akio Hirata1, Yasuharu
6
Takeda1, Yoshio Yasumura1
RI PT
4
SC
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1. Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
9
2. Cardiovascular Division, Osaka National Hospital, Osaka, Japan
10 11
M AN U
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Brief title: Angioplasty of occluded persistent sciatic artery
12 Address for correspondence:
14
Yasunori Ueda
15
Cardiovascular Division, Osaka National Hospital
16
2-1-14 Hoenzaka, Chuo-ku, Osaka, 540-0006 Japan.
17
TEL: +81-6-6942-1331
18
E-mail:
20
EP
FAX: +81-6-6943-6467
[email protected]
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Abstract
22
Persistent sciatic artery is a rare developmental anomaly prone to atherosclerotic
23
disease. We present a case of successful endovascular therapy for left persistent
24
sciatic artery that was occluded at the distal site. The angioplasty was performed
25
with both antegrade approach from contralateral common femoral artery and
26
retrograde approach from ipsilateral superficial femoral artery. The guidewire was
27
advanced via collateral channel and crossed through the lesion retrogradely.
28
Rendez-vous technique was performed and the lesion was successfully dilated by
29
balloon inflation. Angioplasty of occluded sciatic artery can be performed
30
successfully and effectively using the collateral channel.
31
EP
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SC
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Key words:
33
Persistent sciatic artery; Endovascular therapy; Retrograde collateral channel
34
approach; Rendez-vous technique.
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35
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Introduction
38
Persistent sciatic artery (PSA) is a rare vascular anomaly resulting from incomplete
39
obliteration of the sciatic artery during development. Sciatic artery is a major
40
source of blood supply to the lower limb in the early development. In the early
41
embryonic stage, when the embryo reaches approximately 2cm in size, the
42
superficial femoral artery takes over the supply to the lower limb and the sciatic
43
artery becomes discontinuous. In approximately 0.025-0.04% of people, the sciatic
44
artery persists as a main artery supplying the lower limb.1 The condition typically
45
remains asymptomatic until PSA presents atherosclerotic disease, aneurysmal
46
disease, or embolization2, 3. However, PSA, depending on its location and
47
connective tissue defects within the arterial wall5, 6, has a high incidence of
48
atherosclerosis or aneurysm formation causing lower extremity ischemia4.
49
The rendez-vous technique is a useful bidirectional technique for subintimal
50
recanalization. Bidirectional wiring to cross the occluded target lesion often fails
51
and forms true lumen and subintimal lumen separated by intimal membrane inside
52
the occluded target lesion. The rendez-vous technique is to penetrate this intimal
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membrane by a stiff guidewire and advance it into microcatheter waiting in the
54
other lumen to perform externalization15.
55
We report a 67-year-old male patient with unilateral PSA suffering lower extremity
56
ischemia. The PSA was occluded at the distal site with severe calcification. We
57
treated the lesion by rendez-vous technique and balloon angioplasty using the
58
retrograde approach from ipsilateral superficial femoral artery. This is a report on
59
the successful endovascular therapy of PSA using the retrograde approach from
60
ipsilateral superficial femoral artery.
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Case
63
A 67-year-old man with left PSA was admitted with a history of left intermittent
64
claudication for 3 months. He had hypertension, coronary heart disease, diabetes
65
mellitus, dyslipidemia, and chronic kidney disease. He was taking aspirin,
66
clopidogrel, carvedilol, amlodipine, furosemide, pitavastatin, and eicosapentaic
67
acid.
68
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62
Examination of his left lower limb revealed poor femoral pulses, and absent
4
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popliteal and foot pulses. We thought his symptom was severe and worth
70
intervention. He could walk no more than twenty meters without pain, although he
71
did not have pain at rest. Ankle brachial index was 0.78. A lower limb duplex
72
ultrasonography revealed left PSA that was occluded at the distal site. A magnetic
73
resonance angiography and digital subtraction angiogram showed severe
74
calcification of the lesion with collateral channels from distal superficial femoral
75
artery to the distal popliteal artery (Figure 1 and 2).
76
The angioplasty procedure was started with the antegrade approach. We chose
77
the contralateral common femoral artery as an antegrade approach site, because
78
the target lesion had severe calcification and thus we thought we needed a strong
79
backup force. We inserted a 6Fr long sheath (Destination, Terumo, Tokyo, JAPAN)
80
into the right common femoral artery and tried to cross the guidewire antegradely
81
through the right internal iliac artery and PSA. We used several guidewires
82
including tapering stiffness guidewire (Gaia PV and Astato 9-12, ASAHI, Aichi,
83
JAPAN) and a supportive microcatheter (Prominent NEO, Tokai Medical Products,
84
Aichi, JAPAN). However, we could not cross the lesion due to severe calcification
AC C
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SC
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69
5
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(Figure 3A).
86
We thought we needed retrograde approach. The ipsilateral common femoral
87
artery was visible and long enough to insert a sheath. On the other hand, popliteal
88
artery looked hazy and was too short to insert a sheath. Therefore, we inserted 5Fr
89
sheath into the ipsilateral common femoral artery and tried to cross the guidewire
90
through severe tortuous collateral channels from superficial femoral artery. We
91
used hydrophilic soft guidewire (Cruise, ASAHI, Aichi, JAPAN) with a microcatheter
92
(Prominent BTA, Tokai Medical Products, Aichi, JAPAN). Fortunately, we could
93
advance the guidewire through the collateral channel (Figure 3B) and changed the
94
wire to Astato XS (ASAHI, Aichi, JAPAN) to cross the lesion retrogradely.
95
Finally, we performed a Rendez-vous technique at the proximal site of lesion. Then,
96
we performed balloon angioplasty using two balloons (Jackal 4.0x80mm, Kaneka
97
medics Inc., Osaka, JAPAN and Sterling 5.0x220mm, Boston scientific,
98
Massachusetts, USA) and obtained an acceptable result (Figure 4).
99
The postoperative recovery was uneventful and discharged without any
100
complication. We performed post-operative 3-months follow-up. The ankle-brachial
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SC
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85
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index was 1.01 and the lower limb duplex ultrasonography revealed patent PSA.
102
During the 6-months follow-up period, there was no complication or the recurrence
103
of intermittent claudication.
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101
104
Discussion
106
This is a report on the successful endovascular therapy of occluded PSA using the
107
retrograde approach from ipsilateral superficial femoral artery.
108
Green et al. described for the first time in 1831 that PSA is an unusual anatomical
109
anomaly7. PSA was presented in 1960 using angiography by Cowie et al. Bower et
110
al. classified PSA as complete or incomplete4. Complete PSA is the sciatic artery
111
that exits pelvis via sciatic foramen, descends down the posterior thigh, and forms
112
anastomosis with popliteal artery while the superficial femoral artery is hypoplastic
113
and ends in the thigh. Incomplete PSA is the sciatic artery that is interrupted at the
114
superficial femoral artery level, superficial femoral artery serving as main blood
115
supply of the lower limb. Complete PSA constitutes 63% of symptomatic PSA
116
cases treated by bypass or ligation surgery3. PSA in right limb, left limb, and both
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was detected in 36%, 34%, and 30%, respectively, of all reported cases (n=121)
118
from 1964 to 2007 in the Chochrane and Pubmed database9. The average age of
119
symptomatic presentation was 44 years old. The patients usually present
120
claudication, lower extremity ischemia caused by atherosclerosis or distal
121
embolization, painful pulsatile buttock mass, or sciatic neuropathy caused by
122
sciatic nerve compression by the aneurysm. Duplex ultrasonography, digital
123
subtraction angiography, CT angiography, or magnetic resonance angiography can
124
make the diagnosis of PSA10, 11. Angiographic findings include a large internal iliac
125
artery and hypoplastic superficial femoral artery.
126
PSA in an asymptomatic patient does not require any intervention; however,
127
continued follow-up, usually with duplex ultrasonography, is required because of
128
the high incidence of atherosclerotic, aneurysmal, and embolic events. An
129
aneurysm, stenosis, and occlusion of PSA were described in 48% (70 cases), 7%
130
(10 cases) and 9% (13 cases), respectively, of 146 PSA patients reported9 from
131
1964 to 2007.
132
The patients with symptoms are treated either by surgical procedures or by
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133
percutaneous endovascular intervention. The surgical procedures include
134
femoral-popliteal bypass, iliopopliteal transobturator bypass, or interposition
135
bypass5,
136
aneurysm. Since endovascular therapy is still a palliative treatment, we would
137
choose bypass surgery if the patient had recurrence after endovascular therapy.
138
The 1-year symptom-free rate of the patients treated by bypass surgery is over
139
90%12. The percutaneous endovascular intervention is less invasive and requires
140
shorter procedural time. It has less risk of sciatic nerve damage, although it is
141
usually palliative. There are only few reports about percutaneous endovascular
142
intervention of PSA13, 14.
143
In the percutaneous endovascular intervention of PSA, in addition to the antegrade
144
approach through contralateral common femoral artery, we often need ipsilateral
145
retrograde approach due to the restriction of guidewire control from contralateral
146
approach. Retrograde approach can be performed through popliteal artery or
147
through unilateral femoral artery. In the present case, we had three retrograde
148
approach site options. The first option was left common femoral artery as
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. The surgical procedure is selected especially in the cases with
9
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described above. The second option was anterior tibial artery, because anterior
150
tibial artery was visible and received direct blood flow from popliteal artery. We
151
thought it possible to insert a microcatheter to distal anterior tibial artery or to
152
dorsal artery; however, the distal puncture had a definite risk of delayed wound
153
healing at the puncture site. The third option was posterior tibial artery, because
154
posterior tibial artery was also visible. However, posterior tibial artery received
155
blood flow mainly from collateral channels and thus the retrograde approach from
156
posterior tibial artery might be unsuccessful. Although the first option of retrograde
157
approach site to treat PSA occlusion may be popliteal artery, popliteal artery looked
158
hazy and was too short to insert a sheath in the present case. Littler et al. reported
159
the complication of pseudoaneurysm formation during the retrograde approach
160
through popliteal artery13. Since endovascular therapy is still a palliative treatment,
161
we would choose bypass surgery if the patient had restenosis. Because bypass
162
surgery (femoral-popliteal bypass surgery) was the final treatment option, we
163
thought we had to avoid the injury of popliteal artery in the present case. Although
164
the collateral channels from ipsilateral superficial femoral artery tend to be very
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tortuous and small, the recently developed good guidewires can cross the
166
collateral channels. Therefore, if there are collateral channels, we should choose
167
ipsilateral superficial femoral artery as the retrograde approach site.
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168
Conclusion
170
The treatment of symptomatic patients with occluded PSA was successfully
171
performed by percutaneous endovascular intervention using the retrograde
172
approach from ipsilateral superficial femoral artery.
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1.
1977; 18: 317-323.
176
177
2.
Mandell VS, Jaques PF, Delany DJ, et al. Persistent sciatic artery: clinical,
embryologic,
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and
angiographic
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Am
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1985;
144:245-249.
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Greebe J. Congenital anomalies of the iliofemoral artery. J Cardiovasc Surg
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Brantley SK, Rigdon EE, Raju S. Persistent sciatic artery: embryology,
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pathology, and treatment. J Vasc Surg 1993; 18:242-248. 4.
report of two cases and review of the literature. Surgery 1977; 81:588-595.
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5.
Gabelman A, Kramer S, Wisianowski C, et al. Endovascular interventions on persistent sciatic arteries. J Endovasc Ther 2001; 8:622-628.
185
6.
Maldini G, Teruya TH, Kamida C, et al. Combined percutaneous
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Bower E, Smullens S, Parke W. Clinical aspects of persistent sciatic artery:
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endovascular and open surgical approach in the treatment of a persistent
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sciatic artery aneurysm presenting with acute limb-threatening ischemia. A
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case report and review of the literature. Vasc Endovasc Surg 2002; 36:
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403-408.
Lancet 1832; 17: 442: 730–731.
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193
8.
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Cowie TN, Mckellar NJ, McLean N, et al. Unilateral congenital absence of the
external iliac and femoral arteries. Br J Radiol 1960; 33:520–522.
194
195
Green PH. On a new variety of the femoral artery with observations. The
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9.
Van Hooft IM, Zeebregts CJ, van Sterkenburg SM, et al. The persistent sciatic artery. Eur J Vasc Endovasc Surg. 2009;37:585–591.
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10. SreeKumar KP, Prabhu NK, Moorthy S. Bilateral persistent sciatic artery:
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demonstration of the anomaly and its complications with intra-arterial
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contrast enhanced spiral CT. Indian J Radiol Imaging. 2004; 14:205–207.
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11. Jung A, lee W, Chung J, et al. Role of computed tomographic angiography in
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the detection and comprehensive evaluation of persistent sciatic artery. J
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Vasc Surg 2005; 42: 678-683.
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12. Yang S, Ranum K, Malone M, et al. Bilateral Persistent Sciatic Artery with
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Aneurysm Formation and Review of the Literature. Ann Vasc Surg 2014; 28:
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264.e1-264.e7.
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13. Mathias KD, Feldmuller M, Haarmann P, et al. Persistent sciatic artery:
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bilateral percutaneous transluminal angioplasty in ischemic disease.
208
Cardiovasc Intervent Radiol 1993;16:377-379.
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14. Littler P, Blair SD, Lea S. Angioplasty via Retrograde Popliteal Approach in a
210
Stenosed Persistent Sciatic Artery. Eur J Vasc Endovasc Surg 2007;34:
211
212
719-722. 15. Spinosa D, Leung D, Harthun N, et al. Simultaneous antegrade and
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retrograde access for subintimal recanalization of peripheral arterial
214
occlusion. J Vasc Interv Radialol 2013, 14: 1449-1454.
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Figure legends
216
Figure 1. Preoperative magnetic resonance angiography.
217
The presence of complete persistent sciatic artery (PSA) with incompletely
218
developed superficial femoral artery (SFA) was noted. It also presented the
219
complete obstruction of distal PSA with collateral channels from SFA to popliteal
220
artery (Pop artery). Both anterior and posterial tibial arteries (ATA and PTA) were
221
supplied by the collateral channels. PSA originated from internal iliac artery looks
222
relatively patent without any aneurismal change.
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Figure 2. Superficial femoral artery in preoperative digital subtraction
225
angiography.
226
The retrograde collateral channels to the occluded persistent sciatic artery (PSA)
227
was supplied from superficial femoral artery (SFA).
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229
Figure 3. Angioplasty procedure.
230
Druing the antegrade approach, the guidewire could not advance in the proximal
15
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lesion of the occluded PSA due to severe calcification even with the tapered stiff
232
guidewire (A). During the retrograde approach, the hydrophylic soft guidewire
233
could pass through the very tortuous collateral channel from the distal superficial
234
femoral artery (B). CTO, chronic total occlusion.
SC
235
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Figure 4. Final angiogram.
237
Note the patency of persistent sciatic artery (PSA) without dissection around the
238
lesion. Pop artery, popliteal artery; ATA, anterior tibial artery.
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S0890-5096(17)30355-2
DOI:
10.1016/j.avsg.2016.10.053
Reference:
AVSG 3195
To appear in:
Annals of Vascular Surgery
Received Date: 19 July 2016 Revised Date:
5 October 2016
Accepted Date: 11 October 2016
Please cite this article as: Sugihara R, Ueda Y, Nishimoto Y, Takahashi K, Nakano T, Higuchi Y, Kashiwase K, Hirata A, Takeda Y, Yasumura Y, Angioplasty of the occluded persistent sciatic artery using the retrograde approach from superficial femoral artery, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.10.053. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Angioplasty of the occluded persistent sciatic artery using the retrograde approach
2
from superficial femoral artery
3 Ryuta Sugihara1, Yasunori Ueda2, Yuji Nishimoto1, Kuniaki Takahashi1, Tomoaki
5
Nakano1, Yoshiharu Higuchi1, Kazunori Kashiwase1, Akio Hirata1, Yasuharu
6
Takeda1, Yoshio Yasumura1
RI PT
4
SC
7
1. Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
9
2. Cardiovascular Division, Osaka National Hospital, Osaka, Japan
10 11
M AN U
8
Brief title: Angioplasty of occluded persistent sciatic artery
12 Address for correspondence:
14
Yasunori Ueda
15
Cardiovascular Division, Osaka National Hospital
16
2-1-14 Hoenzaka, Chuo-ku, Osaka, 540-0006 Japan.
17
TEL: +81-6-6942-1331
18
E-mail:
20
EP
FAX: +81-6-6943-6467
[email protected]
AC C
19
TE D
13
ACCEPTED MANUSCRIPT
Abstract
22
Persistent sciatic artery is a rare developmental anomaly prone to atherosclerotic
23
disease. We present a case of successful endovascular therapy for left persistent
24
sciatic artery that was occluded at the distal site. The angioplasty was performed
25
with both antegrade approach from contralateral common femoral artery and
26
retrograde approach from ipsilateral superficial femoral artery. The guidewire was
27
advanced via collateral channel and crossed through the lesion retrogradely.
28
Rendez-vous technique was performed and the lesion was successfully dilated by
29
balloon inflation. Angioplasty of occluded sciatic artery can be performed
30
successfully and effectively using the collateral channel.
31
EP
TE D
M AN U
SC
RI PT
21
Key words:
33
Persistent sciatic artery; Endovascular therapy; Retrograde collateral channel
34
approach; Rendez-vous technique.
AC C
32
35
36
2
ACCEPTED MANUSCRIPT
Introduction
38
Persistent sciatic artery (PSA) is a rare vascular anomaly resulting from incomplete
39
obliteration of the sciatic artery during development. Sciatic artery is a major
40
source of blood supply to the lower limb in the early development. In the early
41
embryonic stage, when the embryo reaches approximately 2cm in size, the
42
superficial femoral artery takes over the supply to the lower limb and the sciatic
43
artery becomes discontinuous. In approximately 0.025-0.04% of people, the sciatic
44
artery persists as a main artery supplying the lower limb.1 The condition typically
45
remains asymptomatic until PSA presents atherosclerotic disease, aneurysmal
46
disease, or embolization2, 3. However, PSA, depending on its location and
47
connective tissue defects within the arterial wall5, 6, has a high incidence of
48
atherosclerosis or aneurysm formation causing lower extremity ischemia4.
49
The rendez-vous technique is a useful bidirectional technique for subintimal
50
recanalization. Bidirectional wiring to cross the occluded target lesion often fails
51
and forms true lumen and subintimal lumen separated by intimal membrane inside
52
the occluded target lesion. The rendez-vous technique is to penetrate this intimal
AC C
EP
TE D
M AN U
SC
RI PT
37
3
ACCEPTED MANUSCRIPT
membrane by a stiff guidewire and advance it into microcatheter waiting in the
54
other lumen to perform externalization15.
55
We report a 67-year-old male patient with unilateral PSA suffering lower extremity
56
ischemia. The PSA was occluded at the distal site with severe calcification. We
57
treated the lesion by rendez-vous technique and balloon angioplasty using the
58
retrograde approach from ipsilateral superficial femoral artery. This is a report on
59
the successful endovascular therapy of PSA using the retrograde approach from
60
ipsilateral superficial femoral artery.
M AN U
SC
RI PT
53
TE D
61
Case
63
A 67-year-old man with left PSA was admitted with a history of left intermittent
64
claudication for 3 months. He had hypertension, coronary heart disease, diabetes
65
mellitus, dyslipidemia, and chronic kidney disease. He was taking aspirin,
66
clopidogrel, carvedilol, amlodipine, furosemide, pitavastatin, and eicosapentaic
67
acid.
68
AC C
EP
62
Examination of his left lower limb revealed poor femoral pulses, and absent
4
ACCEPTED MANUSCRIPT
popliteal and foot pulses. We thought his symptom was severe and worth
70
intervention. He could walk no more than twenty meters without pain, although he
71
did not have pain at rest. Ankle brachial index was 0.78. A lower limb duplex
72
ultrasonography revealed left PSA that was occluded at the distal site. A magnetic
73
resonance angiography and digital subtraction angiogram showed severe
74
calcification of the lesion with collateral channels from distal superficial femoral
75
artery to the distal popliteal artery (Figure 1 and 2).
76
The angioplasty procedure was started with the antegrade approach. We chose
77
the contralateral common femoral artery as an antegrade approach site, because
78
the target lesion had severe calcification and thus we thought we needed a strong
79
backup force. We inserted a 6Fr long sheath (Destination, Terumo, Tokyo, JAPAN)
80
into the right common femoral artery and tried to cross the guidewire antegradely
81
through the right internal iliac artery and PSA. We used several guidewires
82
including tapering stiffness guidewire (Gaia PV and Astato 9-12, ASAHI, Aichi,
83
JAPAN) and a supportive microcatheter (Prominent NEO, Tokai Medical Products,
84
Aichi, JAPAN). However, we could not cross the lesion due to severe calcification
AC C
EP
TE D
M AN U
SC
RI PT
69
5
ACCEPTED MANUSCRIPT
(Figure 3A).
86
We thought we needed retrograde approach. The ipsilateral common femoral
87
artery was visible and long enough to insert a sheath. On the other hand, popliteal
88
artery looked hazy and was too short to insert a sheath. Therefore, we inserted 5Fr
89
sheath into the ipsilateral common femoral artery and tried to cross the guidewire
90
through severe tortuous collateral channels from superficial femoral artery. We
91
used hydrophilic soft guidewire (Cruise, ASAHI, Aichi, JAPAN) with a microcatheter
92
(Prominent BTA, Tokai Medical Products, Aichi, JAPAN). Fortunately, we could
93
advance the guidewire through the collateral channel (Figure 3B) and changed the
94
wire to Astato XS (ASAHI, Aichi, JAPAN) to cross the lesion retrogradely.
95
Finally, we performed a Rendez-vous technique at the proximal site of lesion. Then,
96
we performed balloon angioplasty using two balloons (Jackal 4.0x80mm, Kaneka
97
medics Inc., Osaka, JAPAN and Sterling 5.0x220mm, Boston scientific,
98
Massachusetts, USA) and obtained an acceptable result (Figure 4).
99
The postoperative recovery was uneventful and discharged without any
100
complication. We performed post-operative 3-months follow-up. The ankle-brachial
AC C
EP
TE D
M AN U
SC
RI PT
85
6
ACCEPTED MANUSCRIPT
index was 1.01 and the lower limb duplex ultrasonography revealed patent PSA.
102
During the 6-months follow-up period, there was no complication or the recurrence
103
of intermittent claudication.
RI PT
101
104
Discussion
106
This is a report on the successful endovascular therapy of occluded PSA using the
107
retrograde approach from ipsilateral superficial femoral artery.
108
Green et al. described for the first time in 1831 that PSA is an unusual anatomical
109
anomaly7. PSA was presented in 1960 using angiography by Cowie et al. Bower et
110
al. classified PSA as complete or incomplete4. Complete PSA is the sciatic artery
111
that exits pelvis via sciatic foramen, descends down the posterior thigh, and forms
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anastomosis with popliteal artery while the superficial femoral artery is hypoplastic
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and ends in the thigh. Incomplete PSA is the sciatic artery that is interrupted at the
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superficial femoral artery level, superficial femoral artery serving as main blood
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supply of the lower limb. Complete PSA constitutes 63% of symptomatic PSA
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cases treated by bypass or ligation surgery3. PSA in right limb, left limb, and both
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was detected in 36%, 34%, and 30%, respectively, of all reported cases (n=121)
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from 1964 to 2007 in the Chochrane and Pubmed database9. The average age of
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symptomatic presentation was 44 years old. The patients usually present
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claudication, lower extremity ischemia caused by atherosclerosis or distal
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embolization, painful pulsatile buttock mass, or sciatic neuropathy caused by
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sciatic nerve compression by the aneurysm. Duplex ultrasonography, digital
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subtraction angiography, CT angiography, or magnetic resonance angiography can
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make the diagnosis of PSA10, 11. Angiographic findings include a large internal iliac
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artery and hypoplastic superficial femoral artery.
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PSA in an asymptomatic patient does not require any intervention; however,
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continued follow-up, usually with duplex ultrasonography, is required because of
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the high incidence of atherosclerotic, aneurysmal, and embolic events. An
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aneurysm, stenosis, and occlusion of PSA were described in 48% (70 cases), 7%
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(10 cases) and 9% (13 cases), respectively, of 146 PSA patients reported9 from
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1964 to 2007.
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The patients with symptoms are treated either by surgical procedures or by
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percutaneous endovascular intervention. The surgical procedures include
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femoral-popliteal bypass, iliopopliteal transobturator bypass, or interposition
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bypass5,
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aneurysm. Since endovascular therapy is still a palliative treatment, we would
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choose bypass surgery if the patient had recurrence after endovascular therapy.
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The 1-year symptom-free rate of the patients treated by bypass surgery is over
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90%12. The percutaneous endovascular intervention is less invasive and requires
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shorter procedural time. It has less risk of sciatic nerve damage, although it is
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usually palliative. There are only few reports about percutaneous endovascular
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intervention of PSA13, 14.
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In the percutaneous endovascular intervention of PSA, in addition to the antegrade
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approach through contralateral common femoral artery, we often need ipsilateral
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retrograde approach due to the restriction of guidewire control from contralateral
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approach. Retrograde approach can be performed through popliteal artery or
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through unilateral femoral artery. In the present case, we had three retrograde
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approach site options. The first option was left common femoral artery as
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described above. The second option was anterior tibial artery, because anterior
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tibial artery was visible and received direct blood flow from popliteal artery. We
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thought it possible to insert a microcatheter to distal anterior tibial artery or to
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dorsal artery; however, the distal puncture had a definite risk of delayed wound
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healing at the puncture site. The third option was posterior tibial artery, because
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posterior tibial artery was also visible. However, posterior tibial artery received
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blood flow mainly from collateral channels and thus the retrograde approach from
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posterior tibial artery might be unsuccessful. Although the first option of retrograde
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approach site to treat PSA occlusion may be popliteal artery, popliteal artery looked
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hazy and was too short to insert a sheath in the present case. Littler et al. reported
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the complication of pseudoaneurysm formation during the retrograde approach
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through popliteal artery13. Since endovascular therapy is still a palliative treatment,
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we would choose bypass surgery if the patient had restenosis. Because bypass
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surgery (femoral-popliteal bypass surgery) was the final treatment option, we
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thought we had to avoid the injury of popliteal artery in the present case. Although
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the collateral channels from ipsilateral superficial femoral artery tend to be very
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tortuous and small, the recently developed good guidewires can cross the
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collateral channels. Therefore, if there are collateral channels, we should choose
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ipsilateral superficial femoral artery as the retrograde approach site.
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Conclusion
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The treatment of symptomatic patients with occluded PSA was successfully
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performed by percutaneous endovascular intervention using the retrograde
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approach from ipsilateral superficial femoral artery.
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Figure legends
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Figure 1. Preoperative magnetic resonance angiography.
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The presence of complete persistent sciatic artery (PSA) with incompletely
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developed superficial femoral artery (SFA) was noted. It also presented the
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complete obstruction of distal PSA with collateral channels from SFA to popliteal
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artery (Pop artery). Both anterior and posterial tibial arteries (ATA and PTA) were
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supplied by the collateral channels. PSA originated from internal iliac artery looks
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relatively patent without any aneurismal change.
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Figure 2. Superficial femoral artery in preoperative digital subtraction
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angiography.
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The retrograde collateral channels to the occluded persistent sciatic artery (PSA)
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was supplied from superficial femoral artery (SFA).
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Figure 3. Angioplasty procedure.
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Druing the antegrade approach, the guidewire could not advance in the proximal
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lesion of the occluded PSA due to severe calcification even with the tapered stiff
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guidewire (A). During the retrograde approach, the hydrophylic soft guidewire
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could pass through the very tortuous collateral channel from the distal superficial
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femoral artery (B). CTO, chronic total occlusion.
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Figure 4. Final angiogram.
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Note the patency of persistent sciatic artery (PSA) without dissection around the
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lesion. Pop artery, popliteal artery; ATA, anterior tibial artery.
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