Direct occluded vessel puncture technique as a new access site for complex peripheral artery occlusive disease

Abstract

A 77-year-old male was admitted to our hospital for severe intermittent claudication of both legs. He was diagnosed with aorto-iliac occlusions and a right femoro-popliteal artery occlusion with a diseased common femoral artery by a computed tomography angiography of the lower limb. We planned endovascular therapy for these multi-level occlusive lesions. The aorto-iliac lesion of the left side was antegradely recanalized via the left brachial artery. That of the right side was recanalized retrogradely by a direct occlusive vessel puncture (DOVP) with a dedicated 20 G needle and the Hi-Torque Command 18 ST. After stenting, his symptoms were completely relieved without revascularization of right femoro-popliteal artery, and he was discharged without any complications. The DOVP may also be used as an alternative option when there is not an appropriate approach site.

<Learning objective: The appropriate selection of the access site for peripheral artery occlusive disease (PAOD) is one of the most important factors to obtain a successful guidewire recanalization. We occasionally encounter multi-level PAOD without an appropriate access site. The direct occluded vessel puncture should be considered as an alternative option.>

Introduction

Guidewire crossing techniques for peripheral artery occlusive disease (PAOD) including the bi-directional approach technique for aorto-iliac and femoro-popliteal artery (FP) occlusive lesion are developing [1]. In general, the open vessel puncture is the standard choice as antegrade/retrograde approach site for PAOD [2]. However, some complex cases do not have appropriate approach sites due to multi-level lesions or some anatomical issues. Although there are some technical difficulties, the direct occlusive vessel puncture (DOVP) may be considered as an approach for recanalization in patients without an appropriate approach site. We will describe the new technique to achieve the DOVP through the cases we experienced.

Case report

A 77-year-old male was admitted to our hospital for severe intermittent claudication of both legs. The computed tomography (CT) angiography showed bilateral aorto-iliac occlusions. In addition, the right FP was occluded from the ostium with the diseased common femoral artery (Fig. 1A and B). Endovascular therapy (EVT) was chosen as a revascularization method after discussing with the vascular surgeons in our hospital. Although EVT for Leriche syndrome seems to be a high risk for vessel perforation [3], intravascular ultrasound (IVUS) guided wiring could be a useful technique to optimize the route of the guidewire and the device sizing [4]. In addition, a bidirectional approach for the occluded segment could also be one of the effective strategies to enable a successful guidewire crossing [1], therefore we considered it to be the best strategy to provide three access sites for this case, the bilateral femoral arteries, and the left brachial artery. However, the right common femoral artery was not shown in the baseline CT (Fig. 1A).

Fig. 1.

(A) Computed tomography angiography (CTA) of lower limb. CTA showing aorto-bilateral iliac occlusion, right superficial femoral artery occlusion with disease common femoral artery. (B) Abdominal aortography showed the complete occlusion of the terminal abdominal aorta. (C) The final angiogram demonstrated satisfactory flow from the terminal aorta to bilateral common femoral artery.

Antegrade approach

After local anesthesia, 5000 IU of heparin was administered intra-arterially after the insertion of a 90 cm length 6.0 Fr guiding sheath (Medikit, Tokyo, Japan) from his left brachial artery. The guidewire successfully passed the intraluminal through the occlusive lesion to the left FP.

Retrograde approach

For the next step, we decided to use the middle part of the occluded right FP as a retrograde access site. After local anesthesia, the occluded FP was punctured with the dedicated 20 G needle (Medikit) under duplex echo guidance (Fig. 2A). The Hi-Torque Command 18 ST (Command 18) which is a crossing wire with 10 cm nitinol at its distal end providing high support and flexible tip (Century Medical, Inc., Tokyo, Japan) was advanced directly into the occluded FP (Fig. 2B). Next, the microcatheter, Prominent® Raptor (Tokai Medical, Inc., Aichi, Japan) was set inside the 10 cm 6 Fr sheath to reduce the gap between the guidewire and the sheath (Fig. 2C). After the 6 Fr guiding catheter insertion, the guidewire was successfully passed through the intraluminal using the IVUS-guided parallel wiring technique [4] (Fig. 2D and E) and the rendezvous technique (Fig. 2F).

Fig. 2.

(A) The occluded vessel punctured with the 20 G needle under duplex echo guidance. Red arrow showed tip of 20 G needle. (B) The Hi-Torque Command 18 ST was advanced directly into the occluded vessel with J shape. (C) Set of a microcatheter, Prominent® Raptor inside the 10 cm 6Fr sheath was inserted into the occluded vessel. (D) Intravascular ultrasound-guided parallel wiring technique was performed to get intraluminal space. (E) Tip injection from the guiding catheter. (F) The guidewire recanalization was achieved with rendezvous technique.

Revascularization

Bilateral aorto-iliac occlusions were treated with 4 self-expanding nitinol stents (S.M.A.R.T.® 10.0 × 60 mm and 8.0 × 150 mm, Cordis, Dublin, OH, USA). The final angiogram demonstrated a satisfactory flow from the terminal aorta to the bilateral common femoral artery (Fig. 1C). There were no complications such as vessel perforations or distal embolisms.

Hemostasis

The Exoseal® Vascular Closure Devise (Exoseal) (Cordis) was used as the hemostatic device after the DOVP under the fluoroscopic guidance.

Clinical course

After the EVT, his claudication completely disappeared without any complications.

Discussion

The appropriate selection of the access site for a PAOD is one of the most important factors to obtain a successful guidewire recanalization [2]. This time, we first report the feasibility and efficacy of the DOVP technique in combination with the dedicated 20 G needle and the Command 18 for patients without appropriate access sites.

Puncture methods

Whether DOVP is performed with the duplex echo or the fluoroscopic guidance depends on the presence of calcification.

Puncture systems

This DOVP technique requires a dedicated puncture system.

In case of the combination of an IV catheter and a 0.035-in. guidewire, when we advance the 0.035 guidewire to the occluded vessel, the outside plastic sheath tends to back to out of the vessel against the resistance. And the wire prolapses because the outside of the plastic sheath is invisible and has weak supportability (Fig. 3A). In case of the combination of the dedicated 20 G needle and a 0.014-in. soft type of guidewire, the guidewire goes forward against the resistance, and finally it likely breaks (Fig. 3B). On the other hand, the combination of the 20 G needle and the Command 18 is the best balance which has adequate visibility, durability, and pushability. Furthermore, it allows to advance the guidewire into the occluded vessel (Fig. 3C).

Fig. 3.

(A) Combination with IV catheter and 0.035 in. guidewire. (B) Combination with dedicated 20 G needle and 0.014 in. soft type of guidewire. (C) Combination with 20 G needle and the Hi-Torque Command 18 ST.

Hemostasis

In general, the deployment button is depressed according to the absence of the backflow and the change of the indicator color. However, the hemostasis using the Exoseal after the DOVP cannot use this general step due to no blood flow at the puncture site. The fluoroscopic-guided extravascular plug deployment is useful for this type of situation. We pull back the Exoseal carefully and slowly while watching the indicator wire. Then when the indicator wire exits the vessel wall, depress the plug deployment button. In this case, we did not treat the lesion of the puncture site at the same session. Therefore, it is important not to leave any material in the occluded vessel after hemostasis with Exoseal when we schedule a second-stage EVT.

Conclusion

The DOVP using the 20 G needle and the Command 18 is feasible and effective. The DOVP may also be used as an alternative option when there are not appropriate approach sites.

Declaration of Competing Interest

The authors declare that there is no conflict of interest.