- Email: [email protected]
Retrograde Deep Femoral Artery Access as Bailout Technique to Rescue Unexpected Ostial Occlusion during Antegrade Superficial Femoral Artery Recanalization
Journal Pre-proof Retrograde deep femoral artery access as bailout technique to rescue unexpected ostial occlusion during antegrade superficial femoral artery recanalization. Gabriele Testi, MD, PhD, Tanja Ceccacci, MD, PhD, Elisa Paciaroni, MD, Fabio Tarantino, MD, Giorgio Ubaldo Turicchia, MD PII:
S0890-5096(20)30018-2
DOI:
https://doi.org/10.1016/j.avsg.2019.12.041
Reference:
AVSG 4853
To appear in:
Annals of Vascular Surgery
Received Date: 15 November 2019 Revised Date:
15 December 2019
Accepted Date: 17 December 2019
Please cite this article as: Testi G, Ceccacci T, Paciaroni E, Tarantino F, Turicchia GU, Retrograde deep femoral artery access as bailout technique to rescue unexpected ostial occlusion during antegrade superficial femoral artery recanalization., Annals of Vascular Surgery (2020), doi: https://doi.org/10.1016/ j.avsg.2019.12.041. 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. © 2020 Published by Elsevier Inc.
1
Retrograde deep femoral artery access as bailout technique to rescue unexpected ostial
2
occlusion during antegrade superficial femoral artery recanalization.
3 4
Authors:
5
1) Gabriele Testi, MD, PhD
6
Cardiovascular Department, Forlì-Cesena Vascular Surgery Unit, Morgagni-Pierantoni
7
Hospital, Azienda USL della Romagna, Forlì (FC), Italy
8
[email protected]
9
2) Tanja Ceccacci, MD, PhD,
10
Cardiovascular Department, AUSL Romagna, Forlì-Cesena Vascular Surgery Unit, Morgagni-
11
Pierantoni Hospital, Forlì (FC), Italy
12
[email protected]
13
3) Elisa Paciaroni, MD,
14
Cardiovascular Department, AUSL Romagna, Forlì-Cesena Vascular Surgery Unit, Morgagni-
15
Pierantoni Hospital, Forlì (FC), Italy
16
[email protected]
17
4) Fabio Tarantino, MD,
18
Cardiovascular Department, AUSL Romagna, Interventional Cardiology, Morgagni-Pierantoni
19
Hospital, Forlì (FC), Italy
20
[email protected]
21
5) Giorgio Ubaldo Turicchia, MD,
22
Cardiovascular Department, AUSL Romagna, Forlì-Cesena Vascular Surgery Unit, Morgagni-
23
Pierantoni Hospital, Forlì (FC), Italy
24
[email protected] 1
25 26
Total word count: 1038
27 28 29
Declaration of Conflicting Interests
30
The authors declared no potential conflicts of interest with respect to the research, authorship,
31
and/or publication of this article.
32 33
Funding
34
The authors received no financial support for the research, authorship, and/or publication of
35
this article.
36 37
Corresponding Author:
38
Gabriele Testi, Cardiovascular Department, AUSL Romagna, Forlì-Cesena Vascular Surgery
39
Unit, Morgagni-Pierantoni Hospital, Via C. Forlanini 34, 47121 Forlì (FC), Italy
40
Email: [email protected]
41 42 43 44
2
45
ABSTRACT
46 47
We report a case of deep femoral artery (DFA) retrograde access for recanalization of an
48
accidental ostial occlusion complicating an antegrade-retrograde superficial femoral artery
49
(SFA) procedure. A 77-year-old man with chronic limb-threatening ischemia of the right lower
50
limb was submitted to a duplex ultrasound which showed a heavy calcified SFA chronic total
51
occlusion. During antegrade and retrograde attempts to cross the SFA obstruction, a control
52
angiogram unexpectedly showed the ostial occlusion of DFA. Several antegrade attempts to
53
cross the DFA occlusion with various guidewires and catheters were unsuccessfully made.
54
Retrograde access was achieved by direct puncture of the DFA distally to the first perforating
55
artery. With sheathless approach the occlusion was crossed, the retrograde guidewire was
56
externalized through the femoral sheath, and the balloon angioplasty was than antegradely
57
performed. The SFA recanalization was interrupted because of patient discomfort. The patient
58
had an uncomplicated recovery, with immediate resolution of rest pain probably due to the
59
resolution of the underestimated DFA stenosis. The retrograde DFA access is a useful bailout
60
technique in case of accidental ostial occlusion of DFA.
61 62 63 64
3
65
Introduction
66
Even if the surgical approach is considered the first choice in the treatment of long
67
femoropopliteal occlusive disease, endovascular treatment is widely recognized as an option
68
in high-risk patients with chronic limb-threatening ischemia (CLTI). Thanks to the recent
69
technical improvements, even complex lesions such as flush ostial occlusion of the superficial
70
femoral artery (SFA) has been treated with the endovascular techniques. These lesions are a
71
frequent cause of failure of endovascular treatment precluding engagement of SFA.1 When
72
the atherosclerotic process involves the proximal SFA, also the deep femoral artery (DFA) is
73
frequently affected.2 In many cases, the DFA presents focal disease localized in its origin and
74
the proximal portion.2,3 For this reason, management of guidewires and catheters at the SFA
75
origin can compromise the DFA ostium. We report a case of DFA retrograde access as a
76
bailout technique to rescue an accidental occlusion of DFA.
77 78
Case Report
79
A 77-year-old man presented to our attention with CLTI of the right lower limb with untreatable
80
rest pain (Rutherford Class 4). The patient was submitted one year before to a left femoro-
81
peroneal in-situ saphenous vein bypass grafting. The medical history included hypertension,
82
dyslipidemia, kidney transplantation after bilateral nephrectomy, severe aortic valve stenosis,
83
and recent percutaneous endoscopic gastrostomy for aspiration pneumonia.
84
The preprocedural duplex ultrasound showed an SFA chronic total occlusion with extreme
85
parietal calcifications of all lower limb vessels. Antegrade ipsilateral common femoral artery
86
(CFA) access was gained, and a 5F sheath was inserted. The diagnostic angiogram
87
confirmed a heavily calcified ostial flush SFA occlusion and showed an ostial calcified flap of
88
DFA (Figure 1A-B). After few attempts to antegrade cross the SFA obstruction, retrograde 4
89
access to the popliteal artery in the P1 segment was performed (Figure 1C). Before to reenter
90
with the retrograde guidewire in CFA, a control angiogram showed the ostial occlusion of DFA
91
precluding the safety guidewire advancement (Figure 1D). This unexpected finding was
92
probably due to dislodgement of the underestimated ostial calcified DFA stenosis during SFA
93
origin manipulation. Several antegrade attempts to cross the DFA occlusion with various
94
guidewires and catheters were unsuccessfully made. Retrograde access was achieved by
95
direct puncture of the DFA distally to the first perforating branch with a 20-gauge needle
96
(Figure 2A). Since the diffuse DFA heavy calcification, the fluoroscopic-guided puncture was
97
preferred over ultrasonographic technique, which represents the first choice in non-calcified
98
arteries. With sheathless approach, the occlusion was crossed (Figure 2B) with a hydrophilic
99
0.018 guidewire (V18, Boston Scientific, Natick, MA, USA) supported by a Berenstein II
100
catheter (Tempo; Cordis Corporation, a Cardinal Health company, Milpitas, CA, USA). The
101
retrograde guidewire was then externalized through the femoral sheath establishing a flossing
102
wire (Figure 2C). Angioplasty with 4.0x40 balloon (Armada 18, Abbott, Santa Rosa, CA, USA)
103
was than antegradely performed (Figure 2D). The balloon was placed in the puncture site
104
after retrograde guide removal and replacement with a 0.014 guidewire (Hi-Torque
105
Command™ ES, Abbott, Santa Rosa, CA, USA). The balloon was inflated at nominal
106
pressure for 4 minutes to achieve hemostasis (Figure 2E). The control angiogram showed the
107
patency of DFA with complete resolution of the ostial stenosis (Figure 2F). The SFA
108
recanalization was interrupted because of patient discomfort. The patient had an
109
uncomplicated recovery, with immediate resolution of rest pain probably due to the treatment
110
of the unrecognized ostial DFA stenosis. Dual antiplatelet therapy (aspirin 100 mg and
111
clopidogrel 75 mg once daily), started the day before the procedure, was continued for 3
112
months and thereafter aspirin was prescribed long-life. At twelve-month clinical follow-up, no 5
113
recurrent CLTI was present, and a duplex ultrasound examination showed the patency of
114
DFA without significant restenosis or complications in the retrograde puncture site.
115 116
Discussion
117
Endovascular treatment of SFA lesions is rapidly extending its indication because of
118
technological improvements of devices and operators experience. In the case of an SFA flush
119
occlusion or a very short SFA stump, ostial engagement is often challenging and requires
120
extensive management of catheters and guidewires. Whereas atherosclerotic lesions
121
involving the SFA ostium often affect the femoral bifurcation, clearly the treatment of these
122
lesions entails the risk of DFA damage. For this reason, during procedures involving SFA
123
origin, a safety guidewire should always be positioned in DFA. This precaution allows for DFA
124
protection and antegrade sheath stability.4
125
In case of SFA occlusion, DFA represents the most essential collateral vessel to maintain
126
limb viability, and then it is crucial to preserve its patency.5–8 When DFA accidental occlusion
127
occurs without a safety guide in place, it could be impossible to pass through the lesion with a
128
guidewire. In this case, retrograde access to the DFA is a useful bailout technique to rescue
129
the vessel patency.
130
The retrograde puncture of the DFA has been rarely described. There are only two reports in
131
the literature for a total of four patients; all procedure published were planned (elective). Dacie
132
et al.9 reported three cases of angioplasty of a stenosis at the DFA origin performed with
133
retrograde approach. In all patients, the antegrade ipsilateral or contralateral approach was
134
unfeasible for anatomic reasons. More recently, Megaly et al.10, treated a large CFA
135
pseudoaneurysm through a retrograde DFA access. Also in this patient, the standard access
136
was unsuitable. In none of these cases were observed complications at the access site. 6
137
In the case presented in this report, the retrograde access was carried out as a bailout
138
technique to rescue the DFA accidental occlusion. The diffuse dense parietal calcifications of
139
DFA allow for a fluoroscopic-guided puncture given that ultrasounds are unable to accurately
140
visualize the artery. Moreover, considering the DFA parietal characteristics, a sheathless
141
approach was preferred to avoid injuries to the DFA and reduce risk of pseudoaneurysm in
142
the access site. For the same reasons, the angioplasty was performed in antegrade fashion
143
after externalization of the retrograde guidewire avoiding repeated catheters exchange
144
through the sheathless access. The retrograde DFA access could be useful also when a
145
safety guidewire is unfeasible such as during CFA directional atherectomy or ostial stenting of
146
SFA with jailing of DFA.
147 148
Conclusion
149
Accidental occlusion of DFA is a rare but potentially catastrophic complication which could
150
occur during antegrade recanalization of SFA flush occlusion. The retrograde DFA access is
151
a useful bailout technique to restore the patency of DFA when unfeasible via antegrade route.
152 153
Reference
154
1.
Qiu Y, Yu G, Zhou H, Xia H, Chen H, Jiao Y, Wu Z, Zheng X. Determination of Risk
155
Factors and Establishment of a Prediction Model for Immediate Technical Failure during
156
Endovascular Treatment of Femoropopliteal Occlusive Disease. Ann Vasc Surg.
157
2018;48:35-44. doi:10.1016/j.avsg.2017.09.024
158
2.
Beales JSM, Adcock FA, Frawley JS, Nathan B, McLachlan M, Martin P, Steiner R. The
159
radiological assessment of disease of the profunda femoris artery. Br J Radiol.
160
1971;44(527):854-859. doi:10.1259/0007-1285-44-527-854 7
161
3.
the profunda femoris artery. Surgery. 1972;71:182-189.
162 163
Martin P, Frawley J, Barabas A, Rosengarten D. On the surgery of atherosclerosis of
4.
Pua U. Profunda Anchor Technique for Ipsilateral Antegrade Approach in Endovascular
164
Treatment of Superficial Femoral Artery Ostial Occlusion. Cardiovasc Intervent Radiol.
165
2015;38(2):453-456. doi:10.1007/s00270-014-1039-2
166
5.
of the ischemic limb. Arch Surg. 1961;(82):25-31.
167 168
Leeds F, Gilfillan R. Importance of the profunda femoris artery in the revascularization
6.
Morris GJ, Edwards E, Cooley D, Crawford E, De Bakey M. Surgical importance of
169
profunda femoris artery. Analysis of 102 cases with combined aortoiliac and
170
femoropopliteal occlusive disease treated by revascularization of deep femoral artery.
171
Arch Surg. 1961;Jan(82):32-37.
172
7.
experimental study. Surgery. 1966;60:912-918.
173 174
8.
Bernhard W, Ray L, Militello J. The role of angioplasty of the profunda femoris artery in revascularization of the ischemic limb. Surg Gynecol Obs. 1976;142:840-844.
175 176
Waibel P, Wolff G. The collateral circulation in occlusion of the femoral artery: an
9.
Dacie JE, Tennant D. A new approach to percutaneous transluminal angioplasty of
177
profunda femoris origin stenosis. Cardiovasc Intervent Radiol. 1990;13(2):67-70.
178
doi:10.1007/bf02577352
179
10.
Megaly M, Sharma GK, Kumar A, Jones P. Endovascular Repair of a Large Common
180
Femoral Artery Pseudoaneurysm via a Retrograde Deep Femoral Arterial Access.
181
Cardiovasc Intervent Radiol. 2016;39(12):1792-1794. doi:10.1007/s00270-016-1408-0
182 183 184 8
185 186
Figure legends
187
Figure 1: Preprocedural angiograms demonstrate (A) the superficial femoral artery flush
188
occlusion and the patency of the deep femoral artery (DFA) with diffuse heavy wall
189
calcifications, and (B) the ostial calcified flap that determines tight stenosis. (C) The
190
retrograde recanalization of the superficial femoral artery. (D) The control angiogram shows
191
the DFA occlusion.
192 193
Figure 2: Images that show: (A) the retrograde puncture of the deep femoral artery; (B)
194
progression of the retrograde guidewire up to the common femoral artery; (C) externalization
195
of the retrograde guidewire through the femoral sheath; (D) balloon angioplasty in antegrade
196
fashion over the flossing wire; (E) endoluminal hemostasis; (F) final result with restoration of
197
DFA patency and resolution of the ostial stenosis.
9
S0890-5096(20)30018-2
DOI:
https://doi.org/10.1016/j.avsg.2019.12.041
Reference:
AVSG 4853
To appear in:
Annals of Vascular Surgery
Received Date: 15 November 2019 Revised Date:
15 December 2019
Accepted Date: 17 December 2019
Please cite this article as: Testi G, Ceccacci T, Paciaroni E, Tarantino F, Turicchia GU, Retrograde deep femoral artery access as bailout technique to rescue unexpected ostial occlusion during antegrade superficial femoral artery recanalization., Annals of Vascular Surgery (2020), doi: https://doi.org/10.1016/ j.avsg.2019.12.041. 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. © 2020 Published by Elsevier Inc.
1
Retrograde deep femoral artery access as bailout technique to rescue unexpected ostial
2
occlusion during antegrade superficial femoral artery recanalization.
3 4
Authors:
5
1) Gabriele Testi, MD, PhD
6
Cardiovascular Department, Forlì-Cesena Vascular Surgery Unit, Morgagni-Pierantoni
7
Hospital, Azienda USL della Romagna, Forlì (FC), Italy
8
[email protected]
9
2) Tanja Ceccacci, MD, PhD,
10
Cardiovascular Department, AUSL Romagna, Forlì-Cesena Vascular Surgery Unit, Morgagni-
11
Pierantoni Hospital, Forlì (FC), Italy
12
[email protected]
13
3) Elisa Paciaroni, MD,
14
Cardiovascular Department, AUSL Romagna, Forlì-Cesena Vascular Surgery Unit, Morgagni-
15
Pierantoni Hospital, Forlì (FC), Italy
16
[email protected]
17
4) Fabio Tarantino, MD,
18
Cardiovascular Department, AUSL Romagna, Interventional Cardiology, Morgagni-Pierantoni
19
Hospital, Forlì (FC), Italy
20
[email protected]
21
5) Giorgio Ubaldo Turicchia, MD,
22
Cardiovascular Department, AUSL Romagna, Forlì-Cesena Vascular Surgery Unit, Morgagni-
23
Pierantoni Hospital, Forlì (FC), Italy
24
[email protected] 1
25 26
Total word count: 1038
27 28 29
Declaration of Conflicting Interests
30
The authors declared no potential conflicts of interest with respect to the research, authorship,
31
and/or publication of this article.
32 33
Funding
34
The authors received no financial support for the research, authorship, and/or publication of
35
this article.
36 37
Corresponding Author:
38
Gabriele Testi, Cardiovascular Department, AUSL Romagna, Forlì-Cesena Vascular Surgery
39
Unit, Morgagni-Pierantoni Hospital, Via C. Forlanini 34, 47121 Forlì (FC), Italy
40
Email: [email protected]
41 42 43 44
2
45
ABSTRACT
46 47
We report a case of deep femoral artery (DFA) retrograde access for recanalization of an
48
accidental ostial occlusion complicating an antegrade-retrograde superficial femoral artery
49
(SFA) procedure. A 77-year-old man with chronic limb-threatening ischemia of the right lower
50
limb was submitted to a duplex ultrasound which showed a heavy calcified SFA chronic total
51
occlusion. During antegrade and retrograde attempts to cross the SFA obstruction, a control
52
angiogram unexpectedly showed the ostial occlusion of DFA. Several antegrade attempts to
53
cross the DFA occlusion with various guidewires and catheters were unsuccessfully made.
54
Retrograde access was achieved by direct puncture of the DFA distally to the first perforating
55
artery. With sheathless approach the occlusion was crossed, the retrograde guidewire was
56
externalized through the femoral sheath, and the balloon angioplasty was than antegradely
57
performed. The SFA recanalization was interrupted because of patient discomfort. The patient
58
had an uncomplicated recovery, with immediate resolution of rest pain probably due to the
59
resolution of the underestimated DFA stenosis. The retrograde DFA access is a useful bailout
60
technique in case of accidental ostial occlusion of DFA.
61 62 63 64
3
65
Introduction
66
Even if the surgical approach is considered the first choice in the treatment of long
67
femoropopliteal occlusive disease, endovascular treatment is widely recognized as an option
68
in high-risk patients with chronic limb-threatening ischemia (CLTI). Thanks to the recent
69
technical improvements, even complex lesions such as flush ostial occlusion of the superficial
70
femoral artery (SFA) has been treated with the endovascular techniques. These lesions are a
71
frequent cause of failure of endovascular treatment precluding engagement of SFA.1 When
72
the atherosclerotic process involves the proximal SFA, also the deep femoral artery (DFA) is
73
frequently affected.2 In many cases, the DFA presents focal disease localized in its origin and
74
the proximal portion.2,3 For this reason, management of guidewires and catheters at the SFA
75
origin can compromise the DFA ostium. We report a case of DFA retrograde access as a
76
bailout technique to rescue an accidental occlusion of DFA.
77 78
Case Report
79
A 77-year-old man presented to our attention with CLTI of the right lower limb with untreatable
80
rest pain (Rutherford Class 4). The patient was submitted one year before to a left femoro-
81
peroneal in-situ saphenous vein bypass grafting. The medical history included hypertension,
82
dyslipidemia, kidney transplantation after bilateral nephrectomy, severe aortic valve stenosis,
83
and recent percutaneous endoscopic gastrostomy for aspiration pneumonia.
84
The preprocedural duplex ultrasound showed an SFA chronic total occlusion with extreme
85
parietal calcifications of all lower limb vessels. Antegrade ipsilateral common femoral artery
86
(CFA) access was gained, and a 5F sheath was inserted. The diagnostic angiogram
87
confirmed a heavily calcified ostial flush SFA occlusion and showed an ostial calcified flap of
88
DFA (Figure 1A-B). After few attempts to antegrade cross the SFA obstruction, retrograde 4
89
access to the popliteal artery in the P1 segment was performed (Figure 1C). Before to reenter
90
with the retrograde guidewire in CFA, a control angiogram showed the ostial occlusion of DFA
91
precluding the safety guidewire advancement (Figure 1D). This unexpected finding was
92
probably due to dislodgement of the underestimated ostial calcified DFA stenosis during SFA
93
origin manipulation. Several antegrade attempts to cross the DFA occlusion with various
94
guidewires and catheters were unsuccessfully made. Retrograde access was achieved by
95
direct puncture of the DFA distally to the first perforating branch with a 20-gauge needle
96
(Figure 2A). Since the diffuse DFA heavy calcification, the fluoroscopic-guided puncture was
97
preferred over ultrasonographic technique, which represents the first choice in non-calcified
98
arteries. With sheathless approach, the occlusion was crossed (Figure 2B) with a hydrophilic
99
0.018 guidewire (V18, Boston Scientific, Natick, MA, USA) supported by a Berenstein II
100
catheter (Tempo; Cordis Corporation, a Cardinal Health company, Milpitas, CA, USA). The
101
retrograde guidewire was then externalized through the femoral sheath establishing a flossing
102
wire (Figure 2C). Angioplasty with 4.0x40 balloon (Armada 18, Abbott, Santa Rosa, CA, USA)
103
was than antegradely performed (Figure 2D). The balloon was placed in the puncture site
104
after retrograde guide removal and replacement with a 0.014 guidewire (Hi-Torque
105
Command™ ES, Abbott, Santa Rosa, CA, USA). The balloon was inflated at nominal
106
pressure for 4 minutes to achieve hemostasis (Figure 2E). The control angiogram showed the
107
patency of DFA with complete resolution of the ostial stenosis (Figure 2F). The SFA
108
recanalization was interrupted because of patient discomfort. The patient had an
109
uncomplicated recovery, with immediate resolution of rest pain probably due to the treatment
110
of the unrecognized ostial DFA stenosis. Dual antiplatelet therapy (aspirin 100 mg and
111
clopidogrel 75 mg once daily), started the day before the procedure, was continued for 3
112
months and thereafter aspirin was prescribed long-life. At twelve-month clinical follow-up, no 5
113
recurrent CLTI was present, and a duplex ultrasound examination showed the patency of
114
DFA without significant restenosis or complications in the retrograde puncture site.
115 116
Discussion
117
Endovascular treatment of SFA lesions is rapidly extending its indication because of
118
technological improvements of devices and operators experience. In the case of an SFA flush
119
occlusion or a very short SFA stump, ostial engagement is often challenging and requires
120
extensive management of catheters and guidewires. Whereas atherosclerotic lesions
121
involving the SFA ostium often affect the femoral bifurcation, clearly the treatment of these
122
lesions entails the risk of DFA damage. For this reason, during procedures involving SFA
123
origin, a safety guidewire should always be positioned in DFA. This precaution allows for DFA
124
protection and antegrade sheath stability.4
125
In case of SFA occlusion, DFA represents the most essential collateral vessel to maintain
126
limb viability, and then it is crucial to preserve its patency.5–8 When DFA accidental occlusion
127
occurs without a safety guide in place, it could be impossible to pass through the lesion with a
128
guidewire. In this case, retrograde access to the DFA is a useful bailout technique to rescue
129
the vessel patency.
130
The retrograde puncture of the DFA has been rarely described. There are only two reports in
131
the literature for a total of four patients; all procedure published were planned (elective). Dacie
132
et al.9 reported three cases of angioplasty of a stenosis at the DFA origin performed with
133
retrograde approach. In all patients, the antegrade ipsilateral or contralateral approach was
134
unfeasible for anatomic reasons. More recently, Megaly et al.10, treated a large CFA
135
pseudoaneurysm through a retrograde DFA access. Also in this patient, the standard access
136
was unsuitable. In none of these cases were observed complications at the access site. 6
137
In the case presented in this report, the retrograde access was carried out as a bailout
138
technique to rescue the DFA accidental occlusion. The diffuse dense parietal calcifications of
139
DFA allow for a fluoroscopic-guided puncture given that ultrasounds are unable to accurately
140
visualize the artery. Moreover, considering the DFA parietal characteristics, a sheathless
141
approach was preferred to avoid injuries to the DFA and reduce risk of pseudoaneurysm in
142
the access site. For the same reasons, the angioplasty was performed in antegrade fashion
143
after externalization of the retrograde guidewire avoiding repeated catheters exchange
144
through the sheathless access. The retrograde DFA access could be useful also when a
145
safety guidewire is unfeasible such as during CFA directional atherectomy or ostial stenting of
146
SFA with jailing of DFA.
147 148
Conclusion
149
Accidental occlusion of DFA is a rare but potentially catastrophic complication which could
150
occur during antegrade recanalization of SFA flush occlusion. The retrograde DFA access is
151
a useful bailout technique to restore the patency of DFA when unfeasible via antegrade route.
152 153
Reference
154
1.
Qiu Y, Yu G, Zhou H, Xia H, Chen H, Jiao Y, Wu Z, Zheng X. Determination of Risk
155
Factors and Establishment of a Prediction Model for Immediate Technical Failure during
156
Endovascular Treatment of Femoropopliteal Occlusive Disease. Ann Vasc Surg.
157
2018;48:35-44. doi:10.1016/j.avsg.2017.09.024
158
2.
Beales JSM, Adcock FA, Frawley JS, Nathan B, McLachlan M, Martin P, Steiner R. The
159
radiological assessment of disease of the profunda femoris artery. Br J Radiol.
160
1971;44(527):854-859. doi:10.1259/0007-1285-44-527-854 7
161
3.
the profunda femoris artery. Surgery. 1972;71:182-189.
162 163
Martin P, Frawley J, Barabas A, Rosengarten D. On the surgery of atherosclerosis of
4.
Pua U. Profunda Anchor Technique for Ipsilateral Antegrade Approach in Endovascular
164
Treatment of Superficial Femoral Artery Ostial Occlusion. Cardiovasc Intervent Radiol.
165
2015;38(2):453-456. doi:10.1007/s00270-014-1039-2
166
5.
of the ischemic limb. Arch Surg. 1961;(82):25-31.
167 168
Leeds F, Gilfillan R. Importance of the profunda femoris artery in the revascularization
6.
Morris GJ, Edwards E, Cooley D, Crawford E, De Bakey M. Surgical importance of
169
profunda femoris artery. Analysis of 102 cases with combined aortoiliac and
170
femoropopliteal occlusive disease treated by revascularization of deep femoral artery.
171
Arch Surg. 1961;Jan(82):32-37.
172
7.
experimental study. Surgery. 1966;60:912-918.
173 174
8.
Bernhard W, Ray L, Militello J. The role of angioplasty of the profunda femoris artery in revascularization of the ischemic limb. Surg Gynecol Obs. 1976;142:840-844.
175 176
Waibel P, Wolff G. The collateral circulation in occlusion of the femoral artery: an
9.
Dacie JE, Tennant D. A new approach to percutaneous transluminal angioplasty of
177
profunda femoris origin stenosis. Cardiovasc Intervent Radiol. 1990;13(2):67-70.
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doi:10.1007/bf02577352
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10.
Megaly M, Sharma GK, Kumar A, Jones P. Endovascular Repair of a Large Common
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Femoral Artery Pseudoaneurysm via a Retrograde Deep Femoral Arterial Access.
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Cardiovasc Intervent Radiol. 2016;39(12):1792-1794. doi:10.1007/s00270-016-1408-0
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Figure legends
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Figure 1: Preprocedural angiograms demonstrate (A) the superficial femoral artery flush
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occlusion and the patency of the deep femoral artery (DFA) with diffuse heavy wall
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calcifications, and (B) the ostial calcified flap that determines tight stenosis. (C) The
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retrograde recanalization of the superficial femoral artery. (D) The control angiogram shows
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the DFA occlusion.
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Figure 2: Images that show: (A) the retrograde puncture of the deep femoral artery; (B)
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progression of the retrograde guidewire up to the common femoral artery; (C) externalization
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of the retrograde guidewire through the femoral sheath; (D) balloon angioplasty in antegrade
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fashion over the flossing wire; (E) endoluminal hemostasis; (F) final result with restoration of
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DFA patency and resolution of the ostial stenosis.
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