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
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long-term
156:325-328. Murray RR,
Erp
an-
mi-
Radiology
RC,
White
1985;
RI,
femoropopliteal
a boon
WFM,
artery:
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Hewes
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1987;
Dietrich
et al.
stenoses:
or a bust?
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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