Bilateral Chronic Total Occlusions

Percutaneous recanalization of occlusions of the superficial femoral arteries using the Frontrunner CTO catheter.

By Bassam Roukoz, MD; Satish Surabhi, MD; Rebecca Kilfoy, RN, RCIS; Daniel Dadourian, MD; AND Daniel J. McCormick, DO
 

To view the figures related to this article, please refer to the print version of our April issue, page 28.

Endovascular treatment of aortoiliac disease is the preferred option because of high technical success rates and durable primary patency rates. Controversy surrounds the choice of therapies for infrainguinal disease because of the high frequency of chronic occlusion, length of lesions, and diminutive runoff. In the properly selected patient, however, a minimally invasive technique to relieve claudication does have substantial value. There is a limited number of techniques available for the recanalization of femoro-popliteal chronic total occlusions (CTO). This case presentation illustrates the application of a new device specifically designed to open CTOs.

CASE PRESENTATION
Patient History
A 71-year-old white female had a history of hypertension, hypercholesterolemia, smoking, coronary artery disease, and severe claudication. The patient underwent a PTCA/stent procedure (July 2002) of the right coronary artery after an inferior MI. During her cardiovascular rehabilitation (September 2002), she was unable to complete exercising without severe pain in both legs, which limited her ability to continue with her cardiac rehabilitation. Subsequent lower extremity runoff (September 2002) revealed 100% occlusions of both the right and left superficial femoral arteries.

Course of Action
After discussions with the patient, our plan was to complete staged PTCA/stent procedures of both superficial femoral arteries. Based on runoff angiograms and Doppler pulse pressures, we decided to attempt the left superficial femoral artery CTO first, followed by the right side.

Left Lower Limb Angiography
Arteriography of the left lower extremity showed a 100% occlusion in the proximal superficial femoral artery, which reconstituted after approximately 10 cm via collaterals through the profunda femoral artery (Figure 1). The left superficial femoral artery then continued as the popliteal artery, which gave rise to the anterior tibial artery and the tibioperoneal trunk. The anterior tibial artery and the peroneal artery were totally occluded in the proximal segments and recanalized distally from collaterals provided by the posterior tibial artery. There was single vessel runoff to the left foot via the left posterior tibial artery.

Intervention of the Left Superficial Femoral Artery
Percutaneous access was achieved using a 5F sheath in the right femoral artery. A 5F crossover catheter was advanced over the wire and used to access the left common iliac artery. A Terumo Medical Corporation (Tokyo, Japan) exchange length wire was then advanced to the distal portion of the vessel and the 5F crossover catheter and arterial sheath were exchanged for a 6F Balkin sheath (Cook Incorporated, Bloomington, IN), which was placed in the left external iliac artery. The recently FDA-cleared Frontrunner CTO catheter (LuMend, Inc., Redwood City, CA) is used to assist in revascularization of chronic total occlusions (CTOs). The device is a 6F, guide-compatible catheter that employs blunt microdissection to navigate an intraluminal pathway through a CTO, enabling guidewire placement in the distal true lumen. After device activation (jaw opening and closing) and entry through the proximal cap of the CTO (Figure 2), the Frontrunner CTO catheter was advanced through the 10 cm of occluded segment. The Frontrunner CTO catheter was removed and an SV-5 wire (Boston Scientific Corporation, Natick, MA) was placed through the lumen created by the Frontrunner CTO catheter and placed in the distal portion of the left superficial artery without difficulty. A PTA Symmetry balloon 4 mm X 40 mm (Boston Scientific) was advanced over the SV-5 wire and placed in the distal left superficial femoral artery. Multiple serial inflations were performed through the entire length of the CTO. The balloon was then exchanged for a Dynalink 8-mm X 100-mm stent (Guidant Corporation, Indianapolis, IN), which was successfully deployed with a self-expanding mechanism across the recanalized superficial artery. The stent delivery system was removed, and a 5-mm X 40-mm Symmetry balloon was used for postdilatation.

Final Arteriography
Contrast material runoff of the left superficial femoral artery revealed an excellent angiographic result at the 100% CTO of the left superficial femoral artery (Figure 3). There was no evidence of dissection, thrombus, or distal embolization.

Right Lower Limb Angiography
The right superficial femoral artery was 100% occluded in its proximal portion. It reconstitutes in its distal portion via collaterals. There was a total of 16 cm of occlusion (Figure 4). The right superficial femoral artery continues in the right popliteal artery, which gives rise to the right anterior tibial artery and right tibioperoneal trunk. The right anterior tibial artery goes down to the foot. The tibioperoneal trunk divides into the posterior tibial artery and the peroneal branch. The posterior tibial artery is occluded in its midportion. The right peroneal artery had severe diffuse disease.

Intervention of the Right Superficial Femoral Artery 1 Week Postprocedure
Percutaneous access was achieved with use of a 5F sheath in the left femoral artery. A 5F VCF catheter was advanced over the wire and was used to access the right common iliac artery. A Terumo exchange length wire was then advanced in the distal portion of the vessel and the 5F VCF catheter and arterial sheath were exchanged for a 6F Balkin sheath, which was placed in the right external iliac artery. The Frontrunner CTO catheter was used to assist in revascularization of the CTO, as mentioned previously. After device activation (jaw opening and closing) and entry through the proximal cap of the CTO, the Frontrunner CTO catheter was advanced through the 16 cm of occluded segment (Figure 5). The device was then removed, and a V-18 .018-inch wire (Guidant) was advanced and placed in the distal portion of the right superficial femoral artery without difficulty. This wire was later exchanged for a .035-inch Magic Torque (Boston Scientific) wire. A Zilver (Cook Incorporated) 8-mm X 80-mm stent was advanced over the wire and placed in the distal portion of the right superficial femoral artery, and was then deployed. A second Zilver 8-mm X 80-mm stent was then advanced over the wire and deployed proximal to the previously placed stent. The second stent delivery system was then removed, and a 5-mm X 40-mm Ultrathin Diamond balloon (Boston Scientific) was used for postdilatation.

Final Arteriography
Contrast material runoff of the right superficial femoral artery revealed excellent recanalization of the 100% CTO of the right superficial femoral artery (Figure 6). There was brisk runoff into the distal right superficial femoral artery.

COMMENTARY
CTOs in the coronary and peripheral circulations remain a major challenge for the interventional cardiologist. Most failures of percutaneous revascularizations are due to the inability to cross the chronic occlusion with a guidewire.

The Frontrunner CTO catheter is relatively easy and safe to use, and may facilitate crossing CTOs in the peripheral arteries and allow quick distal placement of a guidewire with subsequent PTA and stenting of the lesion. Larger studies are needed to study this device in CTOs in the peripheral arteries.

Bassam Roukoz, MD, is an interventional fellow at Hahneman University Hospital in Philadelphia, Pennsylvania. He does not hold a financial interest in any product mentioned herein. Dr. Roukoz may be reached at broukoz@yahoo.com.

Satish Surabhi, MD, is an interventional fellow at Hahneman University Hospital in Philadelphia, Pennsylvania. He does not hold a financial interest in any product mentioned herein. Dr. Surabhi may be reached at ssurabhi@yahoo.com.

Rebecca Kilfoy, RN, RCIS, is a Nurse Manager, Invasive Cardiac Services, at Hahneman University Hospital in Philadelphia, Pennsylvania. She does not hold a financial interest in any product mentioned herein. Nurse Kilroy may be reached at rebecca.kilfoy@tenethealth.com.

Daniel Dadourian, MD, is an attending invasive and interventional cardiologist at Hahneman University Hospital in Philadelphia, Pennsylvania. He does not hold a financial interest in any product mentioned herein. Dr. Dadourian may be reached at daniel.dadourian@tenethealth.com.

Daniel J. McCormick, DO, is Director of the Cardiac Catheterization Laboratory at Hahnemann University Hospital in Philadelphia, Pennsylvania. He does not hold a financial interest in any product mentioned herein. Dr. McCormick may be reached at (215) 762-7776; daniel.mccormick@tenethealth.com.

 

Contact Info

For advertising rates and opportunities, contact:
Craig McChesney
484-581-1816
cmcchesney@bmctoday.com

Stephen Hoerst
484-581-1817
shoerst@bmctoday.com

Charles Philip
484-581-1873
cphillip@bmctoday.com

About Endovascular Today

Endovascular Today is a publication dedicated to bringing you comprehensive coverage of all the latest technology, techniques, and developments in the endovascular field. Our Editorial Advisory Board is composed of the top endovascular specialists, including interventional cardiologists, interventional radiologists, vascular surgeons, neurologists, and vascular medicine practitioners, and our publication is read by an audience of more than 22,000 members of the endovascular community.