Anna-Maria

Belli,

FRCR

#{149} Anne

Peripheral Recanalizatlon after Guide

repeated

attempts.

Rather

than abandon the procedure, the authors advanced a 2.5-mm laser probe to the occlusion, and the lumen was successfully reentered without the application of laser energy in 12 patients. The authors believe this technique is useful in traversing arterial occlusions after a standard guide wire technique has failed. The developrnent of a wire and catheter with similar properties might allow the more widespread use of this technique. Index

terms:

Arteries,

extremities,

92.721, #{149} Arteries,

986.721 #{149} Arteries, femoral, 92.721 iliac, 986.721 #{149} Arteries, injuries, 92.444, 986.444 #{149} Arteries, laser angioplasty, 92.128, 986.128 #{149} Arteries, stenosis or obstruction, 92.721, 986.721 #{149} Arteries, transluminal angioplasty,

92.128,

FRCR

#{149} David

C

ONVENTIONAL

loon ed.

With

I

From

Hallamshire

methods

angioplasty

of bab-

are well

improvements

accept-

in equip-

ment and expertise, primary success rates in the recanabization of occbusions are improving (1), but subintimal passage of the wire and catheter may occur. Repeated attempts often fail and may extend the dissection distally.

Thermal

laser

probes,

in-

cluding the hybrid probe, have been shown to be effective in the recanabization of occlusions, including those in which conventional methods have failed (2). The shape of the probe undoubtedly contributes mechanically to this

success;

be traversed gy,

some

even

although

occlusions

without

mechanical

can

laser

ener-

pressure

alone will not suffice in very resistant occlusions. We report the use of the laser probe to mechanically reenten the true lumen in cases in which documented

dissection

during conventional canalization and failure would the result.

has

occurred

attempts at mein which technical

otherwise

have

been

986.128

PATIENTS Radiology

C. Cumberland,

1990; 176:539-541

the Department Hospital,

Twelve

of Radiology, Glossop

FRCP,

FRCR

Vascular Occlusions: Mechanical with a Metal Laser Probe Wire Dissection’

Fourteen patients underwent recanalization of occlusions of the iliac or femoral artery. Subintimal passage of the guide wire and catheter occurred and was confirmed on angiograms obtained after administration of contrast medium. Recanalization of the true lumen was impossible, despite

E. Proctor,

Rd,

Royal

Sheffield

510 2JF, England. Received November 30, 1989; revision requested January 26, 1990; revision received April 9; accepted April 18. From the 1989 RSNA scientific assembly. Address reprint requests to A.M.B. c RSNA, 1990

patients

AND with

METHODS femoropopliteal

occlusions ranging from 2 to 25 cm (mean, 9 cm) and two patients with iliac occlusions (3 and 6 cm) underwent attempted conventional percutaneous transluminal angioplasty. In our institution, the standard approach is to use a .035-inch (.089-cm) wine (Mednad, Pittsburgh) with a straight pnedibating catheten for initial attempts to cross the occlusion. Occasionally a pneshaped catheter (eg, femorovisceral) is used to direct the guide wire away from an important adjacent collateral vessel. If this method fails on dissection occurs, the tip of the Medrad wine is formed into a J shape of varying curves, on a preshaped curved J wine or Terumo wire with an angled tip (Tokyo) is used. A Rosen wine (Cook, Bloomington, Ind) is not routinely used, although it was used on one occasion, and reentry into the lumen failed. In our experience,

the use of a combination of such wires and catheters is often successful. Our overall primary success rates oven 9 years

have

been

72% in iliac occlusions

and 81%

in femoropopliteal occlusions (3). These rates are supported by other authors who report 70%-80% primary success rates for crossing long occlusions with a guide wire and catheter (1,4,5). In all cases, the guide wire caused dissection of the anteny, and injection of contrast medium confirmed the subintimal position of the wire (Fig 1). Repeated attempts with a variety of wines and preshaped catheters failed. Rather than abandon the procedure, we inserted a laser probe through an 8-F intnoducen sheath to the proximal extent of the occlusion. Two types of probes were mainly used, either the 2.5-mm hybrid Iasen probe (Spectnaprobe; Trimedyne, Santa Ana, Calif) or the 2.5-mm eccentric lasen probe (Tnimedyne), which passes over

a .035-inch (.089-cm) guide Flex Catheter; Trimedyne).

wire (PLR The hybrid

probe was used in 10 patients, and the lasen probe that passes over the wine was used in three. In one patient, a 2.0-mm lasen probe was used. When the hybrid probe was used, it was advanced to the site of occlusion. The laser was not activated, but the probe was advanced in a continuous motion down to the site of dissection. Gentle pressure was exerted until the probe felt free within the distal true lumen (Fig 2). Similarly, the laser probe and “over-the-wire” probe were advanced oven the wine, which was left in the dissection flap. The probe was then passed beyond the wire and reentered the lumen with gentle pressure. Balloon dilation was performed with a standard technique in patients in whom the occlusion was successfully traversed, but instead of the laser probe being withdrawn and a guide wine being inserted, the laser probe was left in place, and the balloon catheter was fed oven the optical fiber (Figs 3, 4) to avoid losing the track. Although the track was usually easy to find with the laser probe, it was difficult to locate when a standard guide wine was used. The optical fiber was cut with a scalpel at some convenient point along its length to allow the balloon catheter to be fed oven it.

539

la.

lb.

Figures probe

1-4. (la) Guide is passed through

2.

wire is seen the occlusion.

in dissection. (3) Balloon

4.

3.

(ib) Dissection is confirmed with injection of contrast medium. catheter is passed over the optical fiber of the probe. (4) Results

(2) The obtained

2.5-mm hybrid after balloon di-

lation.

RESULTS The

laser

crossing

probes

were

12 of the

successful

of the hybrid probe and wine probe failed in one Subsequent tion was patients

graphic sidual tions.

in

14 occlusions.

Use

over-thecase each.

successful balloon dilaperformed in 1 1 of the 12 with a satisfactory angio-

result stenosis) In one

(ie, less than 25% and no complicaof the

iliac

cation, contrast

DISCUSSION

me-

occlusions,

the hybrid probe reentered lumen at the level of the

the true aortic bifun-

but subsequent injection of material through a catheter

fed over the optical fiber there had been extensive

showed that prior dis-

section.

was

fore

Balloon

not

dilation

performed

because

of the

of arterial rupture. Follow-up in this series of patients has been possible in 10 of the 11 patients who underwent balloon angioplasty after the arterial lumen was

again.

ry success

One was

patient

referred

with from

tamed eight tients,

primaNorth-

in one extension

sion

of the

midsuperficiab

540

#{149} Radiology

or the

anatomy

due

wire and catheter compare the two

to advances technobtechniques,

a randomized trial is necessary, which we are currently undertaking. Before and during this trial, we have

encountered

situations

undoubted

entry

the

Glidewire, since they available, have failed, track being persistently Rather than abandon

yes-

have become with the false entered. the procedure,

we tried the baser probe and found that it readily passed into the preexisting track but then, with only slight

of these patients of the occluan-

mechanical

pressure,

ued

into

distally

the

usually true

arterial

very

resistant

continlu-

(often

sions

in which

force

would

chronic)

undue

occlu-

mechanical

be needed.

In this

series,

the probe was used not to recanalize the occluded lumen but to find the correct tissue plane (ie, reenter the true lumen from a subintimal [on deeper intramural] position into the true distal lumen).

Recanalization

of the

true

lumen

after creating and entering a dissection is not generally considered desirable. It could be argued that angioplasty in these cases would be unsuccessful and lead to early recurrent

there

in

into

men rather than extending the dissection plane. This method must be distinguished from the use of the basen probe as the initial device in mecanalizing all or pant of an occlusion; sometimes this can be achieved without laser energy (eg, in soft, partially organized, or relatively recent occlusions) but may not be applicable in

occlusion

sel wall has occurred during conventional angioplasty attempts. Repeated attempts with curved catheters to abten the direction of the straight guide wires (6) and with wires such as the

11 main-

femoral

failed

to be reviewed

which

by good Doppler ankle-arm indexes (mean, 0.92). Doppler indexes obtamed before angioplasty were not always available. Two patients had recurrence of disease at 6 and 10 months, respectively. An angiogram

obtained showed

have

in guide ogy. To

and symptoms relieved in patients; in four of these pathe findings were supported

was and

methods

needs

em Ireland, and no follow-up has been obtained. Follow-up ranged from 2 to 48 months (mean, months). Patency has been

The primary success rate of conventional angiopbasty is improving, notably with the use of curved cathetens to alter the direction of the wire (6) and with use of the Glidewine (Tenumo) (1,7). The baser probe has been useful in treating “impossible” occlusions, in which conventional has been adverse (eg, chronic popbiteal occlusions extending beyond tibial origins [2]), but its usefulness

there-

risk

found

teny to the origin of the superficial fernorab artery but no change in the distal runoff. In the other patient, clinical recurrence was confirmed by means of a diminished Doppler anklearm index.

(8).

were

In this

small

no complications

series,

and

no

acute recurrent occlusions. Follow-up has shown that such lesions can memain patent for long periods. Obviously, longer and more complete follow-up with more patients would be needed for confirmation, but there is presently no evidence of any increased rate of recurrent occlusion compared with that after apparently uneventful conventional angioplasty. In one iliac occlusion, there had been extensive prior dissection with the guide wire and catheter. Although the probe found the true lumen beyond the dissection, the risk of rupture following dilation was

August

1990

considered too great, and balloon lation was not performed. Although such a technique in the iliac artery

has

been

in the

years

successful

literature

we

and (9),

saw

a large

was

in the

di-

2

retropenitoneab

hematoma occur after conventional angioplasty of a total iliac occlusion had been performed and dissection had occurred. We therefore now do not recommend subsequent balloon dilation to have pbasty,

if such occurred because

section

plane

dissection during the depth

is not

is known iliac angioof the dis-

known.

This

was

success of the these procedue to the

176

#{149} Number

2

4.

1.

Morgenstemn

Bixon the

rate

plasty.

la3.

Cetrajdman

EC.

artery:

of conventional

Radiology

1989;

Cumberland

DC,

angioplasty. Pros and

In:

ods.

Berlin:

Belli

A-M,

CI,

Total

femoropopliteal

success 2.

BR,

R, Martin

cons

Belli

Zeitler in PTA

high

tial 5.

Cumberland

Clin

DC,

Knox

Radiol

1990

(in

long-term

156:325-328. Murray RR,

Erp

an-

mi-

Radiology

RC,

White

1985;

RI,

femoropopliteal

a boon

WFM,

artery:

results.

Hewes

RA,

1987;

Dietrich

et al.

stenoses:

or a bust?

Cumberland

is

Radiology

DC.

plasty

(letter).

wire

E, Bahadir for

J Vasc

of complications

Verlag,

1988; K.

Dotter

of Ra-

successful angioplasty.

8:201-202. Prevention

transluCr#{252}ntzig

Percutaneous Berlin:

Springer-

170-174.

E, Curry

dissection

Hydroangio-

CT,

E, eds.

angioplasty.

Rosenthal

tip”)

Surg

In:

W, Zeitler 1983;

during

assisted

in percutaneous

angioplasty.

transluminal

I.

laser

U, Ill#{233}sI, Fendler

minal

of cobra-

2:97-98.

guide

Horvath

Use

to effect recanalization occlusions. J Intervent

EB, Timbadia

philic

mal

van

transluminal

162:473-476.

Carver

diol

7.

GJ,

femoropopliteal

shaped catheter femoropopliteal

9.

91-97.

and

PVU,

Reidy

false laser

tract thermal

J Intervent

J.

Subinti-

formation probe Radiol

(“hot 1989;

4:19-22.

AM,

CU. The complication peripheral balloon

and

A, Schoop

W, eds. meth-

1989;

of the

1987;

6.

angio-

Laser-assisted

Andel

Percutaneous

angioplasty

technical

E, Seyferth and auxiliary

van

PJ.

Uong-segment

KJ,

172:937-940. A-M.

VM,

gioplasty

of

balloon

Springer-Verlag,

Procter AE, Welsh rate of percutaneous

Laffey

occlusions

Krepel

Bneslau

8.

gioplasty.

Volume

of the

References

not considered a problem in the fernomopopliteal segment, and balloon dilation was performed in all mecanalized lumens, without complication. The reason for the sen probe in “rescuing” dunes is, we presume,

configuration

probe, which is beneficial in reentering the true lumen from a subintimal position. The diameter of the probe may also be relevant. The use of a basen probe without the application of baser energy is an effective way of meentering the lumen. The development of a wine on catheter with similam properties is advocated to allow more widespread use of what we consider a very useful technique. U

reported past

blunt-ended

an-

press).

Radiology

#{149} 541

Peripheral vascular occlusions: mechanical recanalization with a metal laser probe after guide wire dissection.

Fourteen patients underwent recanalization of occlusions of the iliac or femoral artery. Subintimal passage of the guide wire and catheter occurred an...
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