- Email: [email protected]
Recanalization of totally occluded stent of superficial femoral artery with multiple direct stent puncture
Journal Pre-proof Recanalization of Totally Occluded Stent of Superficial Femoral Artery with Multiple Direct Stent Puncture
Ibrahim Halil Ulas Bildirici, Burak Acar, Kurtulus Karauzum, Akın Torun PII:
S1553-8389(19)30468-3
DOI:
https://doi.org/10.1016/j.carrev.2019.07.026
Reference:
CARREV 1660
To appear in:
Cardiovascular Revascularization Medicine
Received date:
31 March 2019
Revised date:
22 July 2019
Accepted date:
23 July 2019
Please cite this article as: I.H.U. Bildirici, B. Acar, K. Karauzum, et al., Recanalization of Totally Occluded Stent of Superficial Femoral Artery with Multiple Direct Stent Puncture, Cardiovascular Revascularization Medicine(2019), https://doi.org/10.1016/ j.carrev.2019.07.026
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. 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.
© 2019 Published by Elsevier.
Journal Pre-proof TITLE PAGE Recanalization of Totally Occluded Stent of Superficial Femoral Artery with Multiple Direct Stent Puncture
Running title. Direct Stent Puncture and SFA In-stent Restenosis Keywords. Direct Stent Puncture, Stent, Restenosis, Superficial Femoral Artery.
oo
f
Ibrahim Halil Ulas Bildirici, MD # Burak Acar , MD
pr
Kurtulus Karauzum , MD
Pr
e-
Akın Torun, MD
#Assoc. Prof
rn
al
1-Department of Cardiology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
Jo u
Corresponding to: Burak Açar, MD
Kocaeli University Medical Faculty, Department of Cardiology, Umuttepe Yerleskesi, 41380, Kocaeli, Turkey. Tel : +90 5334230821. Fax:- E-mail: [email protected]
Journal Pre-proof Recanalization of Totally Occluded Stent of Superficial Femoral Artery with Multiple Direct Stent Puncture Abstract Instent restenosis (ISR) is a frequent complication of endovascular stents implantation, especially in the superficial femoral artery (SFA). Beyond the standard interventions, direct stent puncture (DSP) to the totally occluded SFA increases the success rate of the
f
endovascular procedures. Multiple attempts are required to treat total occlusions most of time.
oo
DSP useful and safe technique and provide good angiographic results. Beside the classical
pr
DSP, in this case we discussed recanalization of totally occluded stent of superficial femoral
e-
artery with bidirectional stent puncture.
Pr
Keywords. Direct Stent Puncture, Stent Restenosis, Superficial Femoral Artery.
al
Introduction
rn
Endovascular treatment of the superficial femoral artery (SFA) has successfully been performed as an alternative to surgery for a long time (1). Intervention with stent implantation
Jo u
to SFA is increased by the experience, restenosis is the well-known problem (1). In-stent restenosis (ISR) and total occlusion are common after SFA interventions (2). In these conditions, treatment options are limited to either re-intervention or surgery. Re-intervention is relatively difficult, because it is not quite easy to pass through the stent. Percutaneous antegrade approach is generally the preferred, effective and safe method for the SFA total occlusion lesions. When the antegrade intervention fails, the retrograde transpopliteal approach may be performed as an alternative entrance. However, transpopliteal approach is not feasible in some patients due to absence of distal vessel flow with totally occluded SFA. Direct stent puncture (DSP) might be an as an alternative technique for those patients (3).
Journal Pre-proof This method was previously described (4) We reported a case with totally occluded superficial femoral artery and treatment was done successfully multiple puncture.
Case Report A 70-year-old male was admitted to our hospital with left lower extremity pain especially walking. He underwent self-expandable stents to left SFA and left common femoral artery
f
three years ago. Two months ago, percutaneous intervention with only balloon dilatation was
oo
made due to instent restenosis. During that procedure, a balloon expandable stent was slipped
pr
off the balloon at the iliac bifurcation, and stent implantation was made from the common
e-
femoral artery through the aorta above the bifurcation level.
The patient admitted to our clinic with left lower extremity pain and especially in the foot
Pr
region and color changes after the last procedure which was performed two months ago. We
al
learned that the patient had discontinued his anti-aggregan drugs for an elective abdominal surgery for one week. Doppler ultrasonography showed total occlusion of left SFA and weak
rn
flow in popliteal artery. The patient diagnosed with acute arterial occlusion and underwent
Jo u
peripheral angiography from right femoral access. It showed totally occluded superficial femoral artery and weak popliteal flow because of collateral (Figure 1A-B, Video 1). It was decided to perform balloon dilatation to common femoral and SFA. Firstly, contralateral approach from the right femoral access was tried but it was not successful because of the dropped stent at bifurcation level (Figure 1D). Later, brachial approach was considered but the patient was 195 cm in height and there was no suitable material to reach SFA. Finally, the patient couldn’t lie down in supine position due to recent abdominal surgery, so, popliteal retrograde approach was not possible.
Journal Pre-proof We planned to make direct stent puncture by double route. First puncture made to proximal part of SFA (21 G needle). We advanced with 0.035-inch standard J type guidewire with support of navicross catheter. (Terumo, USA). We made atherectomy (TemREN, Invamed RD Global, Turkey) with retrograde approach from proximal SFA through common femoral artery (Figure 1C). After that, we made percutaneous transluminal angioplasty (PTA) with 6x150 mm balloon inflation to SFA (Extender, Invamed RD Global, Turkey) and 7x 80 mm balloon inflation to external and common iliac artery (Extender, Invamed RD Global, Turkey)
oo
f
(Figure 1D-1E). After successful recanalization, we made second stent puncture to SFA (Figure 2B-C). After advancing 0.035-inch standard J type guidewire, atherectomy and
pr
multiple balloon dilatation (Extender, Invamed RD Global, Turkey) was made to SFA and
e-
popliteal artery (Figure 2D). Good arterial flow was obtained after intervention and there was
Pr
not any complication or bleeding (Figure 2E-F, Video 2). The hemostasis of puncture site was achieved with only short time light compression. After recanalization of SFA there was not any
rn
Discussion
al
extravasation and complication of access site.
Jo u
In this case report, we defined bidirectional stent puncture in total occluded stent of superficial femoral artery. Recanalization of stents were only achieved with multiple direct stent punctures. Instent restenosis (ISR) and total occlusion is a common, well-known complication in SFA region. Although complication rate of re-intervention is lower than surgery, the intervention is relatively difficult in many cases. The antegrade technique seems to be a good and safe technical strategy to obtain good results but its utility is limited. Because it is quite difficult to pass through the stent due to the organized, fibrothrombotic material and neointimal hyperplasia (5). Additionally, the arterial wall is smooth and damaged in these patients and the guidewires prone to advancing subintimal part of stent (6). Because of this, the risk of dissection and perforation is very high in this group of patients. The
Journal Pre-proof retrograde transpopliteal approach is alternative method but it is less frequently preferred in the patients with good popliteal flow. The success of this approach firmly depends on physical features of the patients and complication rates are relatively higher. Related complications with popliteal approach are puncture site hematoma, pseudoaneurysm, and arteriovenous fistula. A recent study has reported that incidence of complication in transpopliteal approach was 2.5%–5.2% (7).
f
Direct stent puncture (DSP) has been proposed a useful option when classical approaches
oo
failed to recanalize totally occluded peripheral stents. Success rate of anterograde approach
pr
and direct stent puncture for totally occluded SFA was comparable and a study has
e-
demonstrated that recanalization was achieved 98% of patients with DSP (4). No serious complication was observed in that study and clinical improvement was obtained in %94 of the
Pr
cases with DSP (3). It might become more effective method when combined with anterograde intervention. It seems last option when both of the surgery and percutaneous intervention
al
failed. In most of the cases single DSP of the totally occluded segment were enough for
rn
proceeding the intervention., however, some lesions required multiple attends. Previously, it
Jo u
has been described DSP for totally occluded SFA lesion (4, 8) . Single stent puncture was not enough in our case we made double puncture with different direction to totally occluded stents. Retrograde and anterograde approach was not possible and we had to make direct stent puncture with two different sites. Direct stent puncture by two puncture sites provided that recanalization of that totally occluded stent. We thought that SFA had partially occluded by instent restenosis and discontinuation of dual antiplatelet therapy caused total occlusion of it. Therefore, we concluded that the occlusion in this patient was caused by both instent restenosis and thrombotic occlusion. There was no acute thrombosis, hematoma or bleeding at puncture site. This case showed that direct stent puncture could be safely made with multiple puncture site.
Journal Pre-proof This technique has also some limitations that need to be noted. Beside the puncture site complication, collateral vessel injury, iatrogenic stent crush or stent deformation can happen. Selection of the puncture point is the most important step in this technique, care should be taken to select appropriate stent strut guidance with fluoroscopy. Conclusion Multiple direct stent puncture for totally occluded stents may be considered an alternative
oo
f
approach especially in patients with unsuccessful classical approaches.
pr
Conflict of interest
e-
None to declare.
al
Pr
References
Jo u
rn
1. Wojtasik-Bakalarz J, Arif S, Chyrchel M, Rakowski T, Bartus K, Dudek D, et al. Twelve months follow-up after retrograde recanalization of superficial femoral artery chronic total occlusion. Postepy Kardiol Interwencyjnej. 2017;13(1):47-52. 2. Schlager O, Dick P, Sabeti S, Amighi J, Mlekusch W, Minar E, et al. Long-segment SFA stenting-the dark sides: in-stent restenosis, clinical deterioration, and stent fractures. J Endovasc Ther. 2005;12(6):676-84. 3. Gandini R, Del Giudice C, Assako Ondo EP, Spano S, Stefanini M, Simonetti G. Stent puncture for recanalization of occluded superficial femoral artery stents. J Endovasc Ther. 2012;19(1):30-3. 4. Manzi M, Palena LM, Brocco E. Clinical results using the direct stent puncture technique to treat SFA in-stent occlusion. J Endovasc Ther. 2012;19(3):461-2. 5. Scheinert D, Scheinert S, Sax J, Piorkowski C, Braunlich S, Ulrich M, et al. Prevalence and clinical impact of stent fractures after femoropopliteal stenting. J Am Coll Cardiol. 2005;45(2):312-5. 6. Duterloo D, Lohle PN, Lampmann LE. Subintimal double-barrel restenting of an occluded primary stented superficial femoral artery. Cardiovasc Intervent Radiol. 2007;30(3):474-6. 7. Noory E, Rastan A, Sixt S, Schwarzwalder U, Leppannen O, Schwarz T, et al. Arterial puncture closure using a clip device after transpopliteal retrograde approach for recanalization of the superficial femoral artery. J Endovasc Ther. 2008;15(3):310-4. 8. Palena LM, Manzi M. Direct stent puncture technique for intraluminal stent recanalization in the superficial femoral and popliteal arteries in-stent occlusion: outcomes from a prospective clinical analysis of diabetics with critical limb ischemia. Cardiovasc Revasc Med. 2013;14(4):203-6.
Journal Pre-proof
oo
f
Figure Legends
Figure 1. Pre-balloon angiography showing proximal occlusion of SFA (A) and partial filling and
pr
collaterals of distal SFA (B). Direct stent puncture with 21 G needle to totally occluded SFA, advancing 0.035 guidewire and atherectomy (C), balloon inflation (D, E), successful recanalization of
e-
proximal part of SFA and iliac artery (F). It was also seen slipped stent at iliac bifurcation and
al
Pr
previously implanted stent at right common iliac artery (star). SFA, superficial femoral artery.
rn
Figure 2. Pre-balloon angiography showing totally occluded SFA before the second puncture (A). Second stent puncture through the distal part of SFA (B) and advancing 0.035-inch standard J type
Jo u
guidewire (C). Multiple balloon dilatation (D) and successfully recanalization of SFA (E, F). Video 1. Pre-balloon angiography showing totally occlusion above the knee level. Video 2. Angiography showing good flow without any complication after intervention.
Journal Pre-proof Highlights
Instent restenosis is a frequent complication of endovascular stents implantation, especially in the superficial femoral artery.
Multiple, bidirectional direct stent puncture might be an as an alternative technique for those patients
We reported the successful case of using multiple stent puncture to recanalization of totally occluded stent of superficial femoral artery
Jo u
rn
al
Pr
e-
pr
oo
f
Figure 1
Figure 2
Ibrahim Halil Ulas Bildirici, Burak Acar, Kurtulus Karauzum, Akın Torun PII:
S1553-8389(19)30468-3
DOI:
https://doi.org/10.1016/j.carrev.2019.07.026
Reference:
CARREV 1660
To appear in:
Cardiovascular Revascularization Medicine
Received date:
31 March 2019
Revised date:
22 July 2019
Accepted date:
23 July 2019
Please cite this article as: I.H.U. Bildirici, B. Acar, K. Karauzum, et al., Recanalization of Totally Occluded Stent of Superficial Femoral Artery with Multiple Direct Stent Puncture, Cardiovascular Revascularization Medicine(2019), https://doi.org/10.1016/ j.carrev.2019.07.026
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. 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.
© 2019 Published by Elsevier.
Journal Pre-proof TITLE PAGE Recanalization of Totally Occluded Stent of Superficial Femoral Artery with Multiple Direct Stent Puncture
Running title. Direct Stent Puncture and SFA In-stent Restenosis Keywords. Direct Stent Puncture, Stent, Restenosis, Superficial Femoral Artery.
oo
f
Ibrahim Halil Ulas Bildirici, MD # Burak Acar , MD
pr
Kurtulus Karauzum , MD
Pr
e-
Akın Torun, MD
#Assoc. Prof
rn
al
1-Department of Cardiology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
Jo u
Corresponding to: Burak Açar, MD
Kocaeli University Medical Faculty, Department of Cardiology, Umuttepe Yerleskesi, 41380, Kocaeli, Turkey. Tel : +90 5334230821. Fax:- E-mail: [email protected]
Journal Pre-proof Recanalization of Totally Occluded Stent of Superficial Femoral Artery with Multiple Direct Stent Puncture Abstract Instent restenosis (ISR) is a frequent complication of endovascular stents implantation, especially in the superficial femoral artery (SFA). Beyond the standard interventions, direct stent puncture (DSP) to the totally occluded SFA increases the success rate of the
f
endovascular procedures. Multiple attempts are required to treat total occlusions most of time.
oo
DSP useful and safe technique and provide good angiographic results. Beside the classical
pr
DSP, in this case we discussed recanalization of totally occluded stent of superficial femoral
e-
artery with bidirectional stent puncture.
Pr
Keywords. Direct Stent Puncture, Stent Restenosis, Superficial Femoral Artery.
al
Introduction
rn
Endovascular treatment of the superficial femoral artery (SFA) has successfully been performed as an alternative to surgery for a long time (1). Intervention with stent implantation
Jo u
to SFA is increased by the experience, restenosis is the well-known problem (1). In-stent restenosis (ISR) and total occlusion are common after SFA interventions (2). In these conditions, treatment options are limited to either re-intervention or surgery. Re-intervention is relatively difficult, because it is not quite easy to pass through the stent. Percutaneous antegrade approach is generally the preferred, effective and safe method for the SFA total occlusion lesions. When the antegrade intervention fails, the retrograde transpopliteal approach may be performed as an alternative entrance. However, transpopliteal approach is not feasible in some patients due to absence of distal vessel flow with totally occluded SFA. Direct stent puncture (DSP) might be an as an alternative technique for those patients (3).
Journal Pre-proof This method was previously described (4) We reported a case with totally occluded superficial femoral artery and treatment was done successfully multiple puncture.
Case Report A 70-year-old male was admitted to our hospital with left lower extremity pain especially walking. He underwent self-expandable stents to left SFA and left common femoral artery
f
three years ago. Two months ago, percutaneous intervention with only balloon dilatation was
oo
made due to instent restenosis. During that procedure, a balloon expandable stent was slipped
pr
off the balloon at the iliac bifurcation, and stent implantation was made from the common
e-
femoral artery through the aorta above the bifurcation level.
The patient admitted to our clinic with left lower extremity pain and especially in the foot
Pr
region and color changes after the last procedure which was performed two months ago. We
al
learned that the patient had discontinued his anti-aggregan drugs for an elective abdominal surgery for one week. Doppler ultrasonography showed total occlusion of left SFA and weak
rn
flow in popliteal artery. The patient diagnosed with acute arterial occlusion and underwent
Jo u
peripheral angiography from right femoral access. It showed totally occluded superficial femoral artery and weak popliteal flow because of collateral (Figure 1A-B, Video 1). It was decided to perform balloon dilatation to common femoral and SFA. Firstly, contralateral approach from the right femoral access was tried but it was not successful because of the dropped stent at bifurcation level (Figure 1D). Later, brachial approach was considered but the patient was 195 cm in height and there was no suitable material to reach SFA. Finally, the patient couldn’t lie down in supine position due to recent abdominal surgery, so, popliteal retrograde approach was not possible.
Journal Pre-proof We planned to make direct stent puncture by double route. First puncture made to proximal part of SFA (21 G needle). We advanced with 0.035-inch standard J type guidewire with support of navicross catheter. (Terumo, USA). We made atherectomy (TemREN, Invamed RD Global, Turkey) with retrograde approach from proximal SFA through common femoral artery (Figure 1C). After that, we made percutaneous transluminal angioplasty (PTA) with 6x150 mm balloon inflation to SFA (Extender, Invamed RD Global, Turkey) and 7x 80 mm balloon inflation to external and common iliac artery (Extender, Invamed RD Global, Turkey)
oo
f
(Figure 1D-1E). After successful recanalization, we made second stent puncture to SFA (Figure 2B-C). After advancing 0.035-inch standard J type guidewire, atherectomy and
pr
multiple balloon dilatation (Extender, Invamed RD Global, Turkey) was made to SFA and
e-
popliteal artery (Figure 2D). Good arterial flow was obtained after intervention and there was
Pr
not any complication or bleeding (Figure 2E-F, Video 2). The hemostasis of puncture site was achieved with only short time light compression. After recanalization of SFA there was not any
rn
Discussion
al
extravasation and complication of access site.
Jo u
In this case report, we defined bidirectional stent puncture in total occluded stent of superficial femoral artery. Recanalization of stents were only achieved with multiple direct stent punctures. Instent restenosis (ISR) and total occlusion is a common, well-known complication in SFA region. Although complication rate of re-intervention is lower than surgery, the intervention is relatively difficult in many cases. The antegrade technique seems to be a good and safe technical strategy to obtain good results but its utility is limited. Because it is quite difficult to pass through the stent due to the organized, fibrothrombotic material and neointimal hyperplasia (5). Additionally, the arterial wall is smooth and damaged in these patients and the guidewires prone to advancing subintimal part of stent (6). Because of this, the risk of dissection and perforation is very high in this group of patients. The
Journal Pre-proof retrograde transpopliteal approach is alternative method but it is less frequently preferred in the patients with good popliteal flow. The success of this approach firmly depends on physical features of the patients and complication rates are relatively higher. Related complications with popliteal approach are puncture site hematoma, pseudoaneurysm, and arteriovenous fistula. A recent study has reported that incidence of complication in transpopliteal approach was 2.5%–5.2% (7).
f
Direct stent puncture (DSP) has been proposed a useful option when classical approaches
oo
failed to recanalize totally occluded peripheral stents. Success rate of anterograde approach
pr
and direct stent puncture for totally occluded SFA was comparable and a study has
e-
demonstrated that recanalization was achieved 98% of patients with DSP (4). No serious complication was observed in that study and clinical improvement was obtained in %94 of the
Pr
cases with DSP (3). It might become more effective method when combined with anterograde intervention. It seems last option when both of the surgery and percutaneous intervention
al
failed. In most of the cases single DSP of the totally occluded segment were enough for
rn
proceeding the intervention., however, some lesions required multiple attends. Previously, it
Jo u
has been described DSP for totally occluded SFA lesion (4, 8) . Single stent puncture was not enough in our case we made double puncture with different direction to totally occluded stents. Retrograde and anterograde approach was not possible and we had to make direct stent puncture with two different sites. Direct stent puncture by two puncture sites provided that recanalization of that totally occluded stent. We thought that SFA had partially occluded by instent restenosis and discontinuation of dual antiplatelet therapy caused total occlusion of it. Therefore, we concluded that the occlusion in this patient was caused by both instent restenosis and thrombotic occlusion. There was no acute thrombosis, hematoma or bleeding at puncture site. This case showed that direct stent puncture could be safely made with multiple puncture site.
Journal Pre-proof This technique has also some limitations that need to be noted. Beside the puncture site complication, collateral vessel injury, iatrogenic stent crush or stent deformation can happen. Selection of the puncture point is the most important step in this technique, care should be taken to select appropriate stent strut guidance with fluoroscopy. Conclusion Multiple direct stent puncture for totally occluded stents may be considered an alternative
oo
f
approach especially in patients with unsuccessful classical approaches.
pr
Conflict of interest
e-
None to declare.
al
Pr
References
Jo u
rn
1. Wojtasik-Bakalarz J, Arif S, Chyrchel M, Rakowski T, Bartus K, Dudek D, et al. Twelve months follow-up after retrograde recanalization of superficial femoral artery chronic total occlusion. Postepy Kardiol Interwencyjnej. 2017;13(1):47-52. 2. Schlager O, Dick P, Sabeti S, Amighi J, Mlekusch W, Minar E, et al. Long-segment SFA stenting-the dark sides: in-stent restenosis, clinical deterioration, and stent fractures. J Endovasc Ther. 2005;12(6):676-84. 3. Gandini R, Del Giudice C, Assako Ondo EP, Spano S, Stefanini M, Simonetti G. Stent puncture for recanalization of occluded superficial femoral artery stents. J Endovasc Ther. 2012;19(1):30-3. 4. Manzi M, Palena LM, Brocco E. Clinical results using the direct stent puncture technique to treat SFA in-stent occlusion. J Endovasc Ther. 2012;19(3):461-2. 5. Scheinert D, Scheinert S, Sax J, Piorkowski C, Braunlich S, Ulrich M, et al. Prevalence and clinical impact of stent fractures after femoropopliteal stenting. J Am Coll Cardiol. 2005;45(2):312-5. 6. Duterloo D, Lohle PN, Lampmann LE. Subintimal double-barrel restenting of an occluded primary stented superficial femoral artery. Cardiovasc Intervent Radiol. 2007;30(3):474-6. 7. Noory E, Rastan A, Sixt S, Schwarzwalder U, Leppannen O, Schwarz T, et al. Arterial puncture closure using a clip device after transpopliteal retrograde approach for recanalization of the superficial femoral artery. J Endovasc Ther. 2008;15(3):310-4. 8. Palena LM, Manzi M. Direct stent puncture technique for intraluminal stent recanalization in the superficial femoral and popliteal arteries in-stent occlusion: outcomes from a prospective clinical analysis of diabetics with critical limb ischemia. Cardiovasc Revasc Med. 2013;14(4):203-6.
Journal Pre-proof
oo
f
Figure Legends
Figure 1. Pre-balloon angiography showing proximal occlusion of SFA (A) and partial filling and
pr
collaterals of distal SFA (B). Direct stent puncture with 21 G needle to totally occluded SFA, advancing 0.035 guidewire and atherectomy (C), balloon inflation (D, E), successful recanalization of
e-
proximal part of SFA and iliac artery (F). It was also seen slipped stent at iliac bifurcation and
al
Pr
previously implanted stent at right common iliac artery (star). SFA, superficial femoral artery.
rn
Figure 2. Pre-balloon angiography showing totally occluded SFA before the second puncture (A). Second stent puncture through the distal part of SFA (B) and advancing 0.035-inch standard J type
Jo u
guidewire (C). Multiple balloon dilatation (D) and successfully recanalization of SFA (E, F). Video 1. Pre-balloon angiography showing totally occlusion above the knee level. Video 2. Angiography showing good flow without any complication after intervention.
Journal Pre-proof Highlights
Instent restenosis is a frequent complication of endovascular stents implantation, especially in the superficial femoral artery.
Multiple, bidirectional direct stent puncture might be an as an alternative technique for those patients
We reported the successful case of using multiple stent puncture to recanalization of totally occluded stent of superficial femoral artery
Jo u
rn
al
Pr
e-
pr
oo
f
Figure 1
Figure 2