A successful case of “temporary endoluminal bypass technique” using a guide extension catheter during thrombolysis for acute limb ischemia in the non-stenting zone

Abstract

It is still difficult to treat acute limb ischemia (ALI) in the non-stenting zone such as the popliteal artery. We describe a temporary endoluminal bypass technique for ALI in the non-stenting zone using a guide extension catheter. An 83-year-old female was admitted and diagnosed with ALI in her left leg. The angiogram showed a thrombotic obstruction of the left popliteal artery. Aspiration and dilation by angioplasty could not revascularize. Although Fogarty thrombectomy can be applicable, we avoided it because of its risk of complications and performed a temporary endoluminal bypass technique. After evaluating the occluded lesion by intravascular ultrasound, we delivered a guide extension catheter to fully cover it. Because it played the role of an endoluminal bypass, the blood flow to the distal tibial arteries could be confirmed in the angiogram. A thrombolytic drug was administered intra-arterially for the whole day, and the angiogram showed a reduction of the thrombus on postoperative day (POD) 1. On POD 2, the blood flow was maintained without flow limitation even after removing the catheter. Finally, she was discharged without any complications. This technique might be an alternative in cases of failed conventional treatments for ALI although further investigation needs to be undertaken.

<Learning objective: Although endovascular treatment (EVT) has recently been developed, revascularization for acute limb ischemia (ALI) in the non-stenting zone such as popliteal artery has remained the unsolved problem. We report temporary endoluminal bypass technique for ALI in the non-stenting zone using a guide extension catheter. This technique can prevent limb ischemia during thrombolysis. When the conventional EVT procedures fail, it can be an alternative for ALI in the non-stenting zone.>

Introduction

Acute limb ischemia (ALI) is a sudden decrease of limb perfusion that has a potential threat to life and limb viability [1]. Surgical revascularization using an occlusion catheter (Fogarty catheter) has long been the standard approach for the restoration of limb perfusion. However, endovascular treatment (EVT) has developed as an alternative to surgical revascularization for ALI [2], [3], [4], [5], [6], [7]. Despite vast therapeutic modalities available in the current era, ALI continues to be a challenge for vascular specialists [8]. EVT for ALI includes percutaneous aspiration thrombectomy (PAT), catheter-directed thrombolysis (CDT), plain old balloon angioplasty, and stent implantation. Sometimes, we experience ALI patients who cannot be revascularized even with these procedures. Although a self-expandable stent for the iliac and superficial femoral artery can be helpful in these cases, it cannot be used in the “non-stenting zone” such as the common femoral artery (CFA) and the popliteal artery. Therefore, revascularization for ALI in the non-stenting zone has been the unsolved problem.

Here, we describe one endovascular technique for ALI in the non-stenting zone using a guide extension catheter.

Case report

An 83-year-old female was admitted to our hospital with acute rest pain and coldness in her left lower leg 2 days after the onset. On admission, her left lower leg showed ischemic changes, paleness, pulselessness, and coldness. The Doppler could not find the left dorsal pedis nor the posterior tibial pulses. The ankle brachial index was 1.0 on the right and unmeasurable on the left, and the lower extremity ultrasonography revealed an obstruction of the left popliteal artery. She had no medical history of atrial fibrillation or embolism. The laboratory examination findings were as follows: creatine phosphokinase 2517 IU/L, creatinine 1.2 mg/dL, estimated glomerular filtration rate 32.7 mL/min/1.73 m², and d-dimer 13.0 mg/mL. Although 2 days after the onset, some motor function and sensation remained in her leg and the classification of ALI was grade IIb. Therefore, her leg was salvageable with urgent revascularization. The pretreatment angiogram demonstrated an obstruction of the left popliteal artery and below-the-knee artery could not be seen except for a few collateral vessels (Fig. 1a,b).

Fig. 1.

Pretreatment angiogram and temporary endoluminal bypass technique. (a) The pretreatment angiogram revealed an obstruction in the left popliteal artery. (b) The below-the-knee artery could not be seen except for a few collateral vessels. (c) The guide extension catheter was delivered to restore the distal perfusion.

We approached from the ipsilateral left CFA with a 6-F sheath and passed the lesion with a 0.014-in. guidewire (Jupiter FC; Boston Scientific, Tokyo, Japan). A 2.9-F 20 MHz intravascular ultrasound (IVUS) catheter (Eagle-Eye; Volcano Therapeutics, Tokyo, Japan) showed atherosclerotic stenosis with a low echo density plaque and a lot of thrombus, which indicated that the etiology was arterial thrombosis. We performed PAT and angioplasty with a 5.0-mm diameter balloon (ULTRAVERSE RX, Medicon, Osaka, Japan). However, revascularization could not be achieved. We avoided stent implantation because the lesion was located in the non-stenting zone. Generally, Fogarty thrombectomy would be applicable for popliteal ALI. However, we avoided it because we were concerned about the risk of vessel dissection or distal embolization. Therefore, we performed temporary endoluminal bypass technique, which was a deployment of the guide extension catheter into the thrombotic lesion. First, we evaluated the occluded lesion by IVUS to mark both proximal and distal healthy vessels. Then, we delivered a guide extension catheter (6-F GUIDEZILLA II PV; Boston Scientific) to restore distal perfusion (Fig. 1c) and confirmed the contrast flow to the distal arteries (Fig. 2a). Subsequently, urokinase at the dose of 10,000 U/h was administered from the sheath selectively for 24 h. On post-operative day (POD) 1, the angiogram showed a reduction of the thrombus and improved blood flow to the distal arteries (Fig. 2b). On POD 2, they showed an acceptable patency without flow delay, even after removal of the catheter (Fig. 2c). We continued the anticoagulant therapy with heparin until POD 7, and administered aspirin and rivaroxaban. On POD 14, the residual thrombus had disappeared as evidenced by contrast computed tomography (Fig. 2d). She was discharged without any complications on POD 30.

Fig. 2.

The angiographical course. (a) Thrombus was observed in the popliteal artery. The angiogram revealed the blood flow to the distal arteries through the guide extension catheter. The arrow showed the distal edge of the catheter. (b) On POD 1, the angiogram revealed a reduction of thrombus in the popliteal artery and improvement of the blood flow to distal arteries. The arrow shows the distal edge of the catheter. (c) On POD 2, even after removal of the catheter, the angiogram showed acceptable patency without flow delay. (d) Contrast computed tomography on POD14 demonstrated that the residual thrombus was disappeared, and the blood flow was maintained. POD, post-operative day.

Discussion

Temporary endoluminal bypass technique is based on the concept of a perfusion catheter and applied for a treatment of ALI. GUIDEZILLA II PV, which was used in this case, is the guide extension catheter that is composed of a 40-cm silicon tube and a 110-cm stainless steel shaft. Generally, it has been utilized for complex intervention to strengthen the back-up force. In this technique, we used it for prevention of limb ischemia during thrombolysis.

The steps and tips of the technique are as follows. First, we pass the occluded lesion by any wires and measure the lesion length using IVUS. If the distal edge of the lesion cannot be confirmed, tip injection with a microcatheter may be helpful. Based on the measurement of lesion length, we select the guide extension catheters which have enough length to cover the lesion completely. Second, we deliver the guide extension catheter beyond the occluded lesion. It is important that the proximal edge of the guide extension catheter must be separated from the distal tip of the sheath to deliver the blood flow to the distal arteries. Finally, we confirm the contrast flow to the distal arteries through the guide extension catheter (Fig. 3). When the distal blood flow could not be confirmed, we should move the catheter to be more distal or change the vessel to other tibial arteries.

Fig. 3.

The schematic diagram of temporary endoluminal bypass technique. The guide extension catheter was delivered to cover the thrombotic lesion by the part of silicon tube, and we can confirm the contrast flow to the distal arteries.

After setting these situations, we administer the thrombolytic drug intra-arterially. The dose should be decided individually depending on the thrombus volume, renal and hepatic function, past hemorrhage events, or age. There are no defined criteria about the period of the drug administration. We decided to finish it when the antegrade blood flow without flow delay was obtained in the angiogram after removal of the guide extension catheter.

CDT has been accepted as one of the effective resolutions of ALI. It is reported that CDT with an infusion catheter is more effective than systemic thrombolysis [9]. However, CDT is recommended when antegrade flow could be obtained by any interventions or collateral vessels had been developed because it takes time to be revascularized. In this case, the patient suffered from a threat of irreversible limb ischemia. Therefore, we gave priority to revascularization by temporary endoluminal bypass technique over CDT.

The indications of this technique are as follows. Clinically, this technique is recommended for the patients with grade IIa and IIb ALI which are defined as salvageable with immediate revascularization. Although this technique can be also applicable for the patient with grade I ALI which is defined as viable limb without immediate threat, CDT may be conducted at first. Anatomically, it would be useful for both thrombotic and embolic lesions in the non-stenting zone such as popliteal artery and CFA. In the thrombotic case, we may need to dilate the atherosclerotic stenosis by angioplasty to pass the guide extension catheter. Angiographically, the occluded lesion less than 40 cm can be covered by the guide extension catheter. Depending on the lesion length, we can select GUIDEZILLA II PV that is composed of a 40-cm silicon tube, or GuideLiner PV (Japan Lifeline, Tokyo, Japan) that is composed of a 25-cm silicon tube.

The temporary endoluminal bypass technique may be helpful when sufficient blood flow for limb salvage could not be obtained by any interventions. On the other hand, there are some disadvantages in this technique. During delivery of the catheter beyond the occluded lesion, vessel dissection or pushing thrombus into the distal patent vessel can occur. Besides, the patients need bedrest until the removal of all the devices, and they are exposed to the risks of bleeding and infection.

According to the peripheral artery disease guideline, conventional treatments such as PAT, CDT, angioplasty, or thrombectomy should be prioritized to revascularize ALI even in the non-stenting zone. Recently, “The Grab a Clot and Hold On (GACHON) technique” has also been reported as a novel endovascular strategy for ALI in the non-stenting zone [10]. This temporary endoluminal bypass technique might be an alternative in cases of failed conventional treatments for ALI although further investigation needs to be undertaken.

Declaration of Competing Interest

The authors declare that there is no conflict of interest.