Cardiovasc Interv and Ther DOI 10.1007/s12928-014-0304-2
CASE REPORT
A breakthrough trans-collateral retrograde access for occlusive superficial femoral artery: multi-site access and sheaths insertion (MUSASHI) technique Tatsuya Nakama • Yoshisato Shibata • Toshiyuki Kimura • Yusuke Fukushima Yohei Inoue • Nehiro Kuriyama
•
Received: 22 August 2014 / Accepted: 6 October 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract A purpose of this article is to describe a breakthrough technique for occlusive superficial femoral artery (SFA) recanalization: multi-site access and sheaths insertion (MUSASHI) technique. Trans-collateral retrograde approach (TCA) for SFA cannot become popular because it needs conventional (crossover or ipsilateral) approach, which might not be suitable for collateral channel tracking. An innovative MUSASHI technique has a possibility to make TCA popular. Inserting two different sheaths into SFA and profunda artery from common femoral artery, we can manipulate both antegrade and retrograde guidewires without losing their trackability and with strong system-stability. Using MUSASHI technique, TCA may become easier and safer.
fact, many popliteal puncture cases have been done, and puncture techniques have been developed in daily practice [5]. Furthermore, many ‘‘more’’ distal site puncture techniques have also been reported. Tibial or pedal puncture [6–8], high tibial puncture [9], and peroneal puncture [10] are well-known optional procedures for retrograde access for EVT to SFA occlusions. Urasawa et al. reported some cases of trans-collateral retrograde approach (TCA) for SFA occlusions [11]. However, contrary to coronary intervention, TCA techniques have not been able to become popular because of their technical difficulties. In this article, we describe a breakthrough TCA technique for occlusive SFA recanalization: multi-site access and sheaths insertion (MUSASHI) technique.
Introduction
Case report
In recent years, the indication of endovascular therapy (EVT) for superficial femoral artery (SFA) occlusion has expanded widely [1, 2]. However, guidewire crossing to long occlusive SFA still poses some technical challenges. In the case of long SFA occlusions, it has been reported that the standard antegrade guidewire could not cross the lesion in at least 10–20 % of cases [3]. In these situations, retrograde approaches have to be considered for achieving successful guidewire crossing. Popliteal artery puncture [4] is the most common retrograde access technique, and in
A dyslipidemic male in his 60s who had experienced right thigh claudication (Rutherford class 3) while walking from several years ago was presented to our hospital. His right ankle–brachial pressure index (ABP) was decreased (0.68), and duplex ultrasound pointed out an occlusion in his right SFA. At first, administration of cilostazol (200 mg/day) and aspirin (100 mg/day) was started. Exercise therapy was also started. As a result of approximately 3 months of optimal conservative therapy, his maximum walking distance slightly increased. However, this result was not satisfactory for him. Therefore, we finally decided to perform revascularization of his occluded SFA. A diagnostic leg angiogram was performed, and it disclosed that his right SFA occlusion had a small proximal stump and well-developed collateral channels from the profunda artery (Fig. 1A). After discussing therapeutic strategy, we ultimately decided to recanalize his right SFA occlusion with EVT.
T. Nakama (&) Y. Shibata T. Kimura Y. Fukushima Y. Inoue N. Kuriyama Department of Cardiology, Miyazaki Medical Association Hospital, Shinbeppu-cho Funato, Miyazaki City, Miyazaki 738-1, Japan e-mail: [email protected]
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T. Nakama et al. Fig. 1 Male in his 60s came to our hospital due to right thigh claudication. A The control angiogram of the right superficial femoral artery (SFA). It was occluded, and a small proximal stump and welldeveloped collateral channels from the profunda artery were observed. B Final angiogram of this procedure. Three 7.0 9 100 mm self-expandable stents; (Misago, Terumo Co., Tokyo, Japan) were deployed in the SFA. The occluded SFA was successfully recanalized
The right common femoral artery (CFA) was punctured and a 6-Fr 11 cm sheath (Medikit Co., Ltd., Tokyo, Japan) was inserted from the CFA to SFA proximal stump. Unfractionated heparin (5,000 IU) was injected from the side arm of the sheath. Antegrade approach was attempted with a Miracle 12 (ASAHI INTECC CO., LTD., Aichi, Japan) guidewire and back up support of a microcatheter, Prominent (Tokai Medical Products, Inc., Aichi, Japan). Unfortunately, the first guidewire, Miracle 12, got stuck at the distal portion of the SFA. The guidewire was changed to the second guidewire, Conquest Pro (ASAHI INTECC CO., LTD., Aichi, Japan). However, the Conquest Pro entered the subintimal space around the distal fibrous cap, and the antegrade approach failed. Therefore, retrograde approach had to be done. Because there were well-developed collateral channels from the profunda artery to distal SFA, we decided to
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perform TCA with a special technique: MUSASHI technique as described below. The right CFA was punctured again, and a 4-Fr 25 cm sheath (Medikit Co., Ltd., Tokyo, Japan) was deeply inserted to the profunda artery from the CFA (the profunda artery was not punctured). After the sheath insertion (two completely separated systems were inserted into this right CFA, Fig. 2A, B), super-selective collateral angiography was done from the 4-Fr CFA-profunda artery sheath. This clearly visualized the well-developed collateral channels (Fig. 3A). Collateral channel tracking was started with a Regalia XS 1.0 (ASAHI INTECC CO., LTD., Aichi, Japan) and backup support of a Prominent microcatheter from the 4-Fr CFA-profunda sheath. Because we could access the collateral channel directly, the trackability and pushability of the guidewire was quite good. In addition, retrograde system stability was sufficiently strong because the 4-Fr
A breakthrough retrograde access for SFA occlusion
Fig. 2 Two completely separate systems were inserted into the right common femoral artery (CFA). A 6-Fr 11 cm sheath was inserted from the CFA to superficial femoral artery (SFA) for antegrade approach, and a 4-Fr 25 cm sheath was inserted from the CFA to profunda artery for trans-collateral retrograde approach (A, B). Conventional crossover approach and ipsilateral approach would have
had some challenges. In a crossover approach, the trackability of the guidewire can become poor because trackability can be lost at an acute curve at the bifurcation of the terminal aorta. In an ipsilateral approach, we may need to consider the risk of the hemorrhagic complications associated with accidental removal of the inserted sheath because the sheath cannot be inserted deeply
Fig. 3 Super-selective collateral angiography (Fig. 5A) was done from the tip of the retrograde microcatheter. Collateral channel tracking was performed with gentle and precise guidewire manipulation (arrow
a: tip of the retrograde Prominent, arrow b: tip of the retrograde Regalia XS 1.0). After the collateral channel tracking, tip injection clearly visualized the shape of the retrograde distal cap
long sheath was deeply inserted into the profunda artery. Using the retrograde system, a Regalia XS 1.0 and retrograde Prominent easily crossed the tortuous collateral channel, and were able to reach the distal true lumen of the occluded SFA (Fig. 3B–E). After the successful collateral channel tracking, the retrograde guidewire was exchanged to a Miracle 12 and advanced into the occluded SFA. When the retrograde Miracle 12 was advanced into the occlusive SFA deeply enough, the antegrade Prominent was removed, and an intravascular ultrasound (IVUS) catheter, Eagle Eye
Platinum (Volcano Co., San Diego, CA, USA), was inserted. According to the IVUS findings, both guidewires were in the same intraluminal space. Next, antegrade–retrograde wire rendezvous technique [12] was performed. Finally, the antegrade Conquest Pro could be advanced into the inner lumen of the retrograde Prominent, which meant antegrade guidewire crossing was successful (Fig. 4A–E). After the guidewire passage, the occluded SFA was opened with a 4.0 9 220-mm balloon catheter (Coyote, Boston Scientific, Marlborough, MA, USA). After the balloon dilatation, three
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Fig. 4 After establishing the bi-directional approach, antegrade–retrograde wire rendezvous technique was conducted. The antegrade Conquest Pro went into the inner lumen of the retrograde Prominent. ‘‘Achieving a rendezvous’’ meant successful guidewire passage
7.0 9 100-mm self-expandable nitinol stents (Misago, Terumo Co., Tokyo, Japan) were deployed. Post-dilatation was done with a 5.0 9 40-mm balloon (Aviator Plus, Cordis, Johnson & Johnson, Warren, NJ, USA). Figure 1B shows the final angiography. Finally, both 6-Fr and 4-Fr sheaths were removed, and hemostasis procedure was done with conventional manual compression. After the EVT, the patient’s symptoms completely disappeared, and he was discharged from our hospital.
Discussion In this article, we report a case of trans-collateral retrograde approach for SFA occlusion using the MUSASHI technique. This innovative technique may have the possibility to make TCA popular as a retrograde access technique for EVT of occlusive SFA. As we have already mentioned, popliteal artery puncture is the most common strategy for retrograde access [4, 5]. However, conventional popliteal puncture contains some risks of puncture site complications [13, 14] such as a pseudoaneurysm and arteriovenous fistula. In addition, popliteal puncture is impossible in cases where popliteal lesions (stenosis and/or occlusion) exist. Both tibial and peroneal (below-the-knee) artery punctures are good options; however, in similar fashion, these procedures have the same complication risks, and require at least one patent below-the-knee run-off vessel candidate for puncture and device insertion. In daily practice, we often face cases that have no patent below-the-knee run-off vessel in patients suffering from critical limb ischemia. In these cases, with only the conventional distal puncture techniques, it is quite
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difficult to establish a bi-directional approach system. As Urasawa et al. have already reported [11], these cases are well-indicated for TCA. However, TCA has not become popular because of technical difficulties, which are described below. Generally, there are two conventional approach techniques when EVT for SFA occlusion is conducted with TCA. One is a crossover approach from the contralateral CFA, and the other is an ipsilateral antegrade approach from the ipsilateral CFA. Both approach sites present challenges. When a crossover approach is done, it is common for the trackability of the guidewire to become poor, as trackability can be lost at an acute curve at the bifurcation of the terminal aorta. As most physicians know, collateral channel tracking requires very gentle and precise guidewire manipulation; and therefore, a crossover approach may not be suitable for collateral channel tracking. When an ipsilateral antegrade approach is done, we may need to consider the risk of hemorrhagic complications associated with accidental removal of the inserted sheath. When the guidewires are inserted into both the SFA (for antegrade approach) and profunda artery (for TCA) for bi-directional wiring, the sheath cannot be inserted deep down the CFA because there is little distance between the access (puncture) site and the entries of these two arteries. If a guidewire or microcatheter is advanced, the sheath can easily slip out of the body due to the counteracting force from device insertion. Because of these reasons, these two conventional approaches (crossover approach and ipsilateral antegrade approach) are not ideal for TCA. As a result, TCA for SFA occlusion has not become popular, and it is often said to only be an acrobatic performance. However, we propose an innovative
A breakthrough retrograde access for SFA occlusion
Fig. 5 A–C show the collateral channel tracking process in a separate case (arrow a: tip of the Prominent; arrow b: tip of the Regalia XS 1.0). Thanks to good guidewire trackability and system stability, the retrograde Regalia XS 1.0 easily crossed the tortuous collateral channel. The collateral channel was completely stretched after the collateral channel tracking due to the accordion phenomenon. Figure 5D shows the
Controlled Antegrade Retrograde subintimal Tracking (CART) technique with a 4.0 mm short balloon (arrow b: retrograde looped guidewire, arrow c: antegrade guidewire, arrow d: 4.0 9 20 mm balloon for CART technique, delivered from 4-Fr sheath even beyond collateral channels) which was delivered from the profunda sheath beyond the stretched collateral channel (separate case)
technique, named the ‘‘MUSASHI’’ technique. It has great potential to solve the problems regarding trackability of guidewires and system stability, and to make TCA easier and safer. MUSASHI stands for ‘‘multi-site access and sheaths insertion’’. Musashi is the name of a very famous samurai who lived during the 1500s and 1600s in Japan. He is well known for using two ‘‘katana’’ (Japanese swords) during battle. Similarly, we use two independent sheaths in this technique. A 6-Fr sheath is inserted from the CFA to SFA for antegrade approach, and another 4-Fr sheath is inserted from the CFA to profunda artery for retrograde TCA (Fig. 2A, B). By setting up completely separate systems, we can manipulate both antegrade and retrograde guidewires without losing their trackability and have strong system stability.
Figure 5 shows another case of collateral channel tracking with the MUSASHI technique. We carefully advanced the retrograde guidewire, Regalia XS 1.0 into a well-developed collateral channel with the back up support of a Prominent microcatheter from a 4-Fr profunda sheath. When the microcatheter tip reached the middle part of the collateral channel, the Regalia XS 1.0 was removed and tip injection of contrast medium was performed to visualize the collateral channel. Several attempts of tip injection were necessary for collateral channel tracking because the collateral channel shape was changing due to the accordion phenomenon caused by device insertion. Thanks to careful and precise guidewire manipulation, we were able to access the distal true lumen of the SFA beyond the tortuous collaterals. After successful collateral channel tracking, retrograde wiring is normally done so that we can establish a bi-directional wiring system without any additional punctures. It is a useful procedure for (1) patients taking an anticoagulant agent with dual antiplatelet therapy and (2) patients who have bleeding disorders. Of course, because this MUSASHI technique requires two punctures, we must be careful with the hemostatic procedure. In general cases, both puncture sites are close to each other because the length of the punctured CFA is not very long. Therefore, after removal of these sheaths, we can easily compress the two puncture sites simultaneously (like a conventional single-site puncture case). When we face cases in which simultaneous compression is impossible (where there is distance between the two puncture sites), we remove the sheaths one-by-one. This removal procedure requires about twice the time than simultaneous compression. However, this one-by-one removal is safer than simultaneous
1.
2.
Because we can directly approach the collateral channels without any resistance, the trackability and pushability of the guidewires is maintained. Because both sheaths can be deeply inserted into both the SFA and profunda artery, system stability is stronger than that of conventional ipsilateral antegrade approach.
Before two puncture procedures, puncture site information must be carefully evaluated in order to avoid inadequate direct SFA or profunda artery puncture. For this evaluation, computed tomography angiography (CT angiography), magnetic resonance angiography (MR angiography), and duplex ultrasound are useful. In particular, duplexguided puncture is very effective in avoiding these adequate puncture and puncture site complications. Especially in hibifurcated cases, duplex-guided punctures are necessary.
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removal. In cases that have a higher possibility of hemorrhagic complications (such as administration of anti-coagulants, bleeding disorder, or obesity) one-by-one removal is necessary. The utility of MUSASHI technique is not limited to only avoiding retrograde punctures. Because we insert a 4-Fr sheath into the profunda artery, we can deliver a lowprofile balloon catheter from the profunda artery to the distal true lumen of the SFA, even beyond the collateral channels. This allows for conventional CART (controlled antegrade retrograde subintimal tracking) technique [15] and double balloon technique [16, 17], which are important options for guidewire passage, to be performed (Fig. 5D). Of course, the problem of TCA is not only the difficulty of collateral channel tracking. The backup strength of a retrograde system during retrograde wiring is less than that of a distal puncture. Also, this procedure contains the risk of collateral channel injury. Precise and gentle guidewire manipulation is essential. We must sufficiently understand the strengths and limitations of TCA.
Conclusion Trans-collateral angioplasty with the MUSASHI technique is an effective optional retrograde access technique for SFA occlusions.
Conflict of interest
None.
References 1. Norgen L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45 (Suppl):S5–67. 2. European Stroke Organisation, Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Cle´ment D, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the task force on the diagnosis and treatment of peripheral artery diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(22):2851–906. 3. Bown MJ, Bolia A, Sutton AJ. Subintimal angioplasty: metaanalytical evidence of clinical utility. Eur J Vasc Endovasc Surg. 2009;38:323–37.
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4. Cutress ML, Blanshard K, Shaw M, Bown M, White S, Sayers RD. Retrograde subintimal angioplasty via a popliteal artery approach. Eur J Vasc Endovasc Surg. 2002;23:275–6. 5. Tokuda T, Hirano K, Muramatsu T, Tsukahara R, Nakano M. A sheathless retrograde approach via the popliteal artery is useful and safe for treating chronic total occlusions in the superficial femoral artery. J Endovasc Ther. 2014;15:289–95. 6. Fusaro M. Dalla Paola L, Biondi-Zoccai GG. Retrograde posterior tibial artery access for below-the-knee percutaneous revascularization by means of sheathless approach and double wire technique. Minerva Cardioangiol. 2006;54(6):773–7. 7. Hua WR, Yi MQ, Min TL, Feng SN, Xuan LZ, Xing J. Popliteal versus tibial retrograde access for subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique. Eur J Vasc Endovasc Surg. 2013;46(2):249–54. 8. Hosam F. Retrograde pedal/tibial artery access for treatment of infragenicular arterial occlusive disease. Methodist Debakey Cardiovasc J. 2013;9(2):73–8. 9. Iida T, Iida O, Okamoto S, Dohi T, Nanto K, Uematsu M. Endovascular therapy with novel high anterior tibial artery puncture for limb salvage in a case of critical lower limb ischemia. Cardiovasc Interv Ther. 2014; published online 14 January 2014. 10. Zhuang KD, Tan SG, Tay KH. The ‘‘SAFARI’’ technique using retrograde access via peroneal artery access. Cardiovasc Intervent Radiol. 2012;35(4):927–31. 11. Urasawa K, Sato K, Koshida R, Honma Y. Trans-collateral angioplasty for the treatment of long chronic total occlusions of superficial femoral arteries: novel wiring technique. J Cardiovasc Surg (Toriono). 2011;52:1–2. 12. Shimada Y, Kino N, Yano K, Tonomura D, Takehara K, Furuhayashi K, Kurotobi T, Tsuchida T, Fukumoto H. Transcollateral retrograde approach with rendezvous technique for recanalization of chronically occluded tibial arteries. J Endovasc Ther. 2012;19:620–6. 13. Yanagita Y, Noda K. Incidence and risk factors of vascular complications following endovascular treatment of peripheral arterial disease via the popliteal artery. Cardiovasc Interv Ther. 2011;26:209–14. 14. Saim Y, Timur S, Abdullah E, Atalay M, Ersin L. Hematoma after percutaneous transpopliteal stenting and remote suturing of the popliteal artery. J Endovasc Ther. 2002;9:703–6. 15. Surmely JF, Tsuchikane E, Katoh O, Nishida Y, Nakayama M, Nakamura S, Oida A, Hattori E, Suzuki T. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique. J Incas Cardiol. 2006;18: 334–8. 16. Andrej S, Yvonne B, Michael P, Martin W, Sven B, Matthias U, Romon V, Josef F, Johannes S, Spiridon B, Direk S. Retrograde recanalization technique for chronic femoral artery occlusions. J Endovasc Ther. 2012;19:23–9. 17. George LA, Steve JG, Jon G, Jihad AM. Exotic access, techniques, and devices for infrapopliteal CTOs, recommendations on how to successfully cross chronic total occlusions of the infrapopliteal vasculature. Endovasc Today. 2012;5:44–9.
CASE REPORT
A breakthrough trans-collateral retrograde access for occlusive superficial femoral artery: multi-site access and sheaths insertion (MUSASHI) technique Tatsuya Nakama • Yoshisato Shibata • Toshiyuki Kimura • Yusuke Fukushima Yohei Inoue • Nehiro Kuriyama
•
Received: 22 August 2014 / Accepted: 6 October 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract A purpose of this article is to describe a breakthrough technique for occlusive superficial femoral artery (SFA) recanalization: multi-site access and sheaths insertion (MUSASHI) technique. Trans-collateral retrograde approach (TCA) for SFA cannot become popular because it needs conventional (crossover or ipsilateral) approach, which might not be suitable for collateral channel tracking. An innovative MUSASHI technique has a possibility to make TCA popular. Inserting two different sheaths into SFA and profunda artery from common femoral artery, we can manipulate both antegrade and retrograde guidewires without losing their trackability and with strong system-stability. Using MUSASHI technique, TCA may become easier and safer.
fact, many popliteal puncture cases have been done, and puncture techniques have been developed in daily practice [5]. Furthermore, many ‘‘more’’ distal site puncture techniques have also been reported. Tibial or pedal puncture [6–8], high tibial puncture [9], and peroneal puncture [10] are well-known optional procedures for retrograde access for EVT to SFA occlusions. Urasawa et al. reported some cases of trans-collateral retrograde approach (TCA) for SFA occlusions [11]. However, contrary to coronary intervention, TCA techniques have not been able to become popular because of their technical difficulties. In this article, we describe a breakthrough TCA technique for occlusive SFA recanalization: multi-site access and sheaths insertion (MUSASHI) technique.
Introduction
Case report
In recent years, the indication of endovascular therapy (EVT) for superficial femoral artery (SFA) occlusion has expanded widely [1, 2]. However, guidewire crossing to long occlusive SFA still poses some technical challenges. In the case of long SFA occlusions, it has been reported that the standard antegrade guidewire could not cross the lesion in at least 10–20 % of cases [3]. In these situations, retrograde approaches have to be considered for achieving successful guidewire crossing. Popliteal artery puncture [4] is the most common retrograde access technique, and in
A dyslipidemic male in his 60s who had experienced right thigh claudication (Rutherford class 3) while walking from several years ago was presented to our hospital. His right ankle–brachial pressure index (ABP) was decreased (0.68), and duplex ultrasound pointed out an occlusion in his right SFA. At first, administration of cilostazol (200 mg/day) and aspirin (100 mg/day) was started. Exercise therapy was also started. As a result of approximately 3 months of optimal conservative therapy, his maximum walking distance slightly increased. However, this result was not satisfactory for him. Therefore, we finally decided to perform revascularization of his occluded SFA. A diagnostic leg angiogram was performed, and it disclosed that his right SFA occlusion had a small proximal stump and well-developed collateral channels from the profunda artery (Fig. 1A). After discussing therapeutic strategy, we ultimately decided to recanalize his right SFA occlusion with EVT.
T. Nakama (&) Y. Shibata T. Kimura Y. Fukushima Y. Inoue N. Kuriyama Department of Cardiology, Miyazaki Medical Association Hospital, Shinbeppu-cho Funato, Miyazaki City, Miyazaki 738-1, Japan e-mail: [email protected]
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T. Nakama et al. Fig. 1 Male in his 60s came to our hospital due to right thigh claudication. A The control angiogram of the right superficial femoral artery (SFA). It was occluded, and a small proximal stump and welldeveloped collateral channels from the profunda artery were observed. B Final angiogram of this procedure. Three 7.0 9 100 mm self-expandable stents; (Misago, Terumo Co., Tokyo, Japan) were deployed in the SFA. The occluded SFA was successfully recanalized
The right common femoral artery (CFA) was punctured and a 6-Fr 11 cm sheath (Medikit Co., Ltd., Tokyo, Japan) was inserted from the CFA to SFA proximal stump. Unfractionated heparin (5,000 IU) was injected from the side arm of the sheath. Antegrade approach was attempted with a Miracle 12 (ASAHI INTECC CO., LTD., Aichi, Japan) guidewire and back up support of a microcatheter, Prominent (Tokai Medical Products, Inc., Aichi, Japan). Unfortunately, the first guidewire, Miracle 12, got stuck at the distal portion of the SFA. The guidewire was changed to the second guidewire, Conquest Pro (ASAHI INTECC CO., LTD., Aichi, Japan). However, the Conquest Pro entered the subintimal space around the distal fibrous cap, and the antegrade approach failed. Therefore, retrograde approach had to be done. Because there were well-developed collateral channels from the profunda artery to distal SFA, we decided to
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perform TCA with a special technique: MUSASHI technique as described below. The right CFA was punctured again, and a 4-Fr 25 cm sheath (Medikit Co., Ltd., Tokyo, Japan) was deeply inserted to the profunda artery from the CFA (the profunda artery was not punctured). After the sheath insertion (two completely separated systems were inserted into this right CFA, Fig. 2A, B), super-selective collateral angiography was done from the 4-Fr CFA-profunda artery sheath. This clearly visualized the well-developed collateral channels (Fig. 3A). Collateral channel tracking was started with a Regalia XS 1.0 (ASAHI INTECC CO., LTD., Aichi, Japan) and backup support of a Prominent microcatheter from the 4-Fr CFA-profunda sheath. Because we could access the collateral channel directly, the trackability and pushability of the guidewire was quite good. In addition, retrograde system stability was sufficiently strong because the 4-Fr
A breakthrough retrograde access for SFA occlusion
Fig. 2 Two completely separate systems were inserted into the right common femoral artery (CFA). A 6-Fr 11 cm sheath was inserted from the CFA to superficial femoral artery (SFA) for antegrade approach, and a 4-Fr 25 cm sheath was inserted from the CFA to profunda artery for trans-collateral retrograde approach (A, B). Conventional crossover approach and ipsilateral approach would have
had some challenges. In a crossover approach, the trackability of the guidewire can become poor because trackability can be lost at an acute curve at the bifurcation of the terminal aorta. In an ipsilateral approach, we may need to consider the risk of the hemorrhagic complications associated with accidental removal of the inserted sheath because the sheath cannot be inserted deeply
Fig. 3 Super-selective collateral angiography (Fig. 5A) was done from the tip of the retrograde microcatheter. Collateral channel tracking was performed with gentle and precise guidewire manipulation (arrow
a: tip of the retrograde Prominent, arrow b: tip of the retrograde Regalia XS 1.0). After the collateral channel tracking, tip injection clearly visualized the shape of the retrograde distal cap
long sheath was deeply inserted into the profunda artery. Using the retrograde system, a Regalia XS 1.0 and retrograde Prominent easily crossed the tortuous collateral channel, and were able to reach the distal true lumen of the occluded SFA (Fig. 3B–E). After the successful collateral channel tracking, the retrograde guidewire was exchanged to a Miracle 12 and advanced into the occluded SFA. When the retrograde Miracle 12 was advanced into the occlusive SFA deeply enough, the antegrade Prominent was removed, and an intravascular ultrasound (IVUS) catheter, Eagle Eye
Platinum (Volcano Co., San Diego, CA, USA), was inserted. According to the IVUS findings, both guidewires were in the same intraluminal space. Next, antegrade–retrograde wire rendezvous technique [12] was performed. Finally, the antegrade Conquest Pro could be advanced into the inner lumen of the retrograde Prominent, which meant antegrade guidewire crossing was successful (Fig. 4A–E). After the guidewire passage, the occluded SFA was opened with a 4.0 9 220-mm balloon catheter (Coyote, Boston Scientific, Marlborough, MA, USA). After the balloon dilatation, three
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Fig. 4 After establishing the bi-directional approach, antegrade–retrograde wire rendezvous technique was conducted. The antegrade Conquest Pro went into the inner lumen of the retrograde Prominent. ‘‘Achieving a rendezvous’’ meant successful guidewire passage
7.0 9 100-mm self-expandable nitinol stents (Misago, Terumo Co., Tokyo, Japan) were deployed. Post-dilatation was done with a 5.0 9 40-mm balloon (Aviator Plus, Cordis, Johnson & Johnson, Warren, NJ, USA). Figure 1B shows the final angiography. Finally, both 6-Fr and 4-Fr sheaths were removed, and hemostasis procedure was done with conventional manual compression. After the EVT, the patient’s symptoms completely disappeared, and he was discharged from our hospital.
Discussion In this article, we report a case of trans-collateral retrograde approach for SFA occlusion using the MUSASHI technique. This innovative technique may have the possibility to make TCA popular as a retrograde access technique for EVT of occlusive SFA. As we have already mentioned, popliteal artery puncture is the most common strategy for retrograde access [4, 5]. However, conventional popliteal puncture contains some risks of puncture site complications [13, 14] such as a pseudoaneurysm and arteriovenous fistula. In addition, popliteal puncture is impossible in cases where popliteal lesions (stenosis and/or occlusion) exist. Both tibial and peroneal (below-the-knee) artery punctures are good options; however, in similar fashion, these procedures have the same complication risks, and require at least one patent below-the-knee run-off vessel candidate for puncture and device insertion. In daily practice, we often face cases that have no patent below-the-knee run-off vessel in patients suffering from critical limb ischemia. In these cases, with only the conventional distal puncture techniques, it is quite
123
difficult to establish a bi-directional approach system. As Urasawa et al. have already reported [11], these cases are well-indicated for TCA. However, TCA has not become popular because of technical difficulties, which are described below. Generally, there are two conventional approach techniques when EVT for SFA occlusion is conducted with TCA. One is a crossover approach from the contralateral CFA, and the other is an ipsilateral antegrade approach from the ipsilateral CFA. Both approach sites present challenges. When a crossover approach is done, it is common for the trackability of the guidewire to become poor, as trackability can be lost at an acute curve at the bifurcation of the terminal aorta. As most physicians know, collateral channel tracking requires very gentle and precise guidewire manipulation; and therefore, a crossover approach may not be suitable for collateral channel tracking. When an ipsilateral antegrade approach is done, we may need to consider the risk of hemorrhagic complications associated with accidental removal of the inserted sheath. When the guidewires are inserted into both the SFA (for antegrade approach) and profunda artery (for TCA) for bi-directional wiring, the sheath cannot be inserted deep down the CFA because there is little distance between the access (puncture) site and the entries of these two arteries. If a guidewire or microcatheter is advanced, the sheath can easily slip out of the body due to the counteracting force from device insertion. Because of these reasons, these two conventional approaches (crossover approach and ipsilateral antegrade approach) are not ideal for TCA. As a result, TCA for SFA occlusion has not become popular, and it is often said to only be an acrobatic performance. However, we propose an innovative
A breakthrough retrograde access for SFA occlusion
Fig. 5 A–C show the collateral channel tracking process in a separate case (arrow a: tip of the Prominent; arrow b: tip of the Regalia XS 1.0). Thanks to good guidewire trackability and system stability, the retrograde Regalia XS 1.0 easily crossed the tortuous collateral channel. The collateral channel was completely stretched after the collateral channel tracking due to the accordion phenomenon. Figure 5D shows the
Controlled Antegrade Retrograde subintimal Tracking (CART) technique with a 4.0 mm short balloon (arrow b: retrograde looped guidewire, arrow c: antegrade guidewire, arrow d: 4.0 9 20 mm balloon for CART technique, delivered from 4-Fr sheath even beyond collateral channels) which was delivered from the profunda sheath beyond the stretched collateral channel (separate case)
technique, named the ‘‘MUSASHI’’ technique. It has great potential to solve the problems regarding trackability of guidewires and system stability, and to make TCA easier and safer. MUSASHI stands for ‘‘multi-site access and sheaths insertion’’. Musashi is the name of a very famous samurai who lived during the 1500s and 1600s in Japan. He is well known for using two ‘‘katana’’ (Japanese swords) during battle. Similarly, we use two independent sheaths in this technique. A 6-Fr sheath is inserted from the CFA to SFA for antegrade approach, and another 4-Fr sheath is inserted from the CFA to profunda artery for retrograde TCA (Fig. 2A, B). By setting up completely separate systems, we can manipulate both antegrade and retrograde guidewires without losing their trackability and have strong system stability.
Figure 5 shows another case of collateral channel tracking with the MUSASHI technique. We carefully advanced the retrograde guidewire, Regalia XS 1.0 into a well-developed collateral channel with the back up support of a Prominent microcatheter from a 4-Fr profunda sheath. When the microcatheter tip reached the middle part of the collateral channel, the Regalia XS 1.0 was removed and tip injection of contrast medium was performed to visualize the collateral channel. Several attempts of tip injection were necessary for collateral channel tracking because the collateral channel shape was changing due to the accordion phenomenon caused by device insertion. Thanks to careful and precise guidewire manipulation, we were able to access the distal true lumen of the SFA beyond the tortuous collaterals. After successful collateral channel tracking, retrograde wiring is normally done so that we can establish a bi-directional wiring system without any additional punctures. It is a useful procedure for (1) patients taking an anticoagulant agent with dual antiplatelet therapy and (2) patients who have bleeding disorders. Of course, because this MUSASHI technique requires two punctures, we must be careful with the hemostatic procedure. In general cases, both puncture sites are close to each other because the length of the punctured CFA is not very long. Therefore, after removal of these sheaths, we can easily compress the two puncture sites simultaneously (like a conventional single-site puncture case). When we face cases in which simultaneous compression is impossible (where there is distance between the two puncture sites), we remove the sheaths one-by-one. This removal procedure requires about twice the time than simultaneous compression. However, this one-by-one removal is safer than simultaneous
1.
2.
Because we can directly approach the collateral channels without any resistance, the trackability and pushability of the guidewires is maintained. Because both sheaths can be deeply inserted into both the SFA and profunda artery, system stability is stronger than that of conventional ipsilateral antegrade approach.
Before two puncture procedures, puncture site information must be carefully evaluated in order to avoid inadequate direct SFA or profunda artery puncture. For this evaluation, computed tomography angiography (CT angiography), magnetic resonance angiography (MR angiography), and duplex ultrasound are useful. In particular, duplexguided puncture is very effective in avoiding these adequate puncture and puncture site complications. Especially in hibifurcated cases, duplex-guided punctures are necessary.
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removal. In cases that have a higher possibility of hemorrhagic complications (such as administration of anti-coagulants, bleeding disorder, or obesity) one-by-one removal is necessary. The utility of MUSASHI technique is not limited to only avoiding retrograde punctures. Because we insert a 4-Fr sheath into the profunda artery, we can deliver a lowprofile balloon catheter from the profunda artery to the distal true lumen of the SFA, even beyond the collateral channels. This allows for conventional CART (controlled antegrade retrograde subintimal tracking) technique [15] and double balloon technique [16, 17], which are important options for guidewire passage, to be performed (Fig. 5D). Of course, the problem of TCA is not only the difficulty of collateral channel tracking. The backup strength of a retrograde system during retrograde wiring is less than that of a distal puncture. Also, this procedure contains the risk of collateral channel injury. Precise and gentle guidewire manipulation is essential. We must sufficiently understand the strengths and limitations of TCA.
Conclusion Trans-collateral angioplasty with the MUSASHI technique is an effective optional retrograde access technique for SFA occlusions.
Conflict of interest
None.
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