Long Segment Disease
The combination of several new technologies for treating the SFA allowed for the treatment of a 6-year-old chronic total occlusion measuring 20 cm.
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A 53-year-old, white man with a history of significant coronary artery disease, previous inferior wall myocardial infarction, and subsequent balloon angioplasty procedures to the right coronary artery and circumflex marginal branch in 1997 and 1998, respectively, followed by subsequent four vessel coronary artery bypass graft surgery performed in 2000 presented to our office for treatment; he also had lifestyle-limiting exertional right leg claudication. The patient had undergone right common iliac artery Wallstent (Boston Scientific Corporation, Natick, MA) placement a number of years previously and had a documented 6-year-old chronic total occlusion of the right midsuperficial femoral artery. He had been managed conservatively for a number of years but had become progressively more symptomatic and presented with a significant right calf claudication with just mild exertion.
Noninvasive duplex studies over the years had demonstrated progressive decline in the resting ankle/brachial resting indices, which at presentation were 0.66 on the right and 1.02 on the left. The noninvasive duplex examination suggested patency of the common right iliac artery Wallstent and persistent occlusion of the right superficial femoral artery over a 5-cm to 10-cm segment. Repeat lower extremity arteriography confirmed the persistent nature of the right superficial femoral artery occlusion with bridging collateralization (Figure 1). Additionally, there is also progressive disease in the more proximal vessel (Figure 2), which appears to affect the collaterals downstream, thus explaining the progressive nature of this patient’s symptoms.
The interventional management of this patient was believed to be complex for several reasons. This total occlusion had been documented to be present for at least the past 6 years. Additionally, there was a long segment of diffuse disease in the more proximal reference vessel and so the total diseased segment was almost 20 cm in length. However, given his cardiac history, we believed the patient still warranted an attempt at interventional management rather than surgical bypass. Accordingly, arrangements were made to attempt recanalization and subsequent percutaneous intervention of the right superficial femoral artery.
Because the proximal referenced vessel disease was near the right superficial femoral artery ostium, the best approach to this intervention was believed to be from the contralateral left femoral approach using a crossover guiding sheath. A 7-F Balkan contralateral guiding sheath was thus placed into the right common femoral artery from the left femoral approach over a Magic Torque guidewire. A LuMend MicroGuide catheter (Redwood City, CA) was advanced up to the site of total occlusion over a 0.014-inch BHW guidewire. Given the longstanding nature of the total occlusion, it was believed to be best approached initially with a LuMend Frontrunner device. A 140-cm Frontrunner X39 device was advanced through the MicroGuide catheter to the proximal cap of the total occlusion. The Frontrunner device was successful in transversing the total occlusion in a surprisingly rapid fashion (total crossing time less than 2 minutes). The MicroGuide catheter was then advanced over the Frontrunner X39 device and a distal injection was performed through the MicroGuide, which confirmed lumenal patency of the device without subtimal passage (Figure 3). A 0.014-inch BHW guidewire was then advanced into the popliteal segment through the MicroGuide catheter, which was then withdrawn.
After crossing the chronic total occlusion with the Frontrunner X39 device, excisional atherectomy of the totally occluded segment and of the proximal reference diseased vessel was performed using a 7-F SilverHawk atherectomy catheter (FoxHollow Technologies, Menlo Park, CA) (Figure 4). Multiple cuts were made, with removal of a substantial amount of atherosclerotic plaque (Figure 5). Adjunctive balloon angioplasty was then performed with a 5-mm X 10-cm Savvy balloon (Cordis Corporation, a Johnson & Johnson company, Miami, FL) both at this total occlusion site and proximally in the proximal reference vessel diseased segment (Figure 6).
Final angiography after adequate balloon dilation demonstrated a superior ?stent-like? result with generally not more than 10% residual stenoses (Figures 7 and 8). The lesions were not believed to need stenting, and the procedure was concluded after adequate atherectomy and balloon angioplasty (Figure 9).
The patient’s postprocedure course was uneventful, and he was discharged the following morning in a much-improved ambulatory status. Subsequent follow-up, lower-extremity duplex examination revealed normal perfusion to the right lower extremity with resting ankle/brachial index now normalized at 0.99. The left remained normal at 1.03.
This case illustrates how exceedingly complex femoral anatomy can now be approached with new technologies, such as the LuMend Frontrunner X39 device in combination with the FoxHollow SilverHawk atherectomy catheter, with spectacular angiographic results. Previously, the chance of success in crossing a 6-year-old chronic total occlusion would be predictably low, and even if feasible, would have required prolonged fluoroscopy and procedure times to recanalize the vessel. Also, we now have an excellent debulking catheter to reduce the plaque burden in diffusely diseased vessels such as this. With the combination of these two devices, complex diffuse disease can be managed successfully and with shortened procedure times (note the crossing time of the lesion was less than 2 minutes).
Whether debulking and balloon angiography alone without adjunctive stent placement affords the patient 1-year primary patency rates equivalent to that of endovascular stenting is not known. However, we do know that long segment disease that is treated with endovascular stents is associated with a high recurrence rates requiring secondary procedures. In this setting, with more than 20 cm of disease present, it appeared reasonable to treat this patient without adequate stent placement given the “stent-like” results that were achieved with atherectomy and angioplasty alone. A prospective registry and/or randomized trials are recommended to determine if this strategy is indeed equivalent or superior to primary stent placement for diffuse disease.
Robert M. Bersin, MD, is Director of Peripheral Invasive Laboratories, Carolinas Heart Institute, Charlotte, North Carolina, and Co-Director, Vascular Division, The Sanger Clinic, Charlotte, North Carolina. His spouse is an employee of LuMend, Inc. Dr. Bersin may be reached at (888) SANGERC; firstname.lastname@example.org