Cath Lab Digest

A 69-year-old woman who had previous aortobifemoral bypass approximately 15 years prior to admission presented with complaints of bilateral exertional claudication but significantly worse in the left leg. Her ABI was 0.3 in the left leg and 0.4 in the right. Abdominal aortography with runoff showed a patent graft to the common femoral arteries bilaterally with occlusion of the left SFA at its ostium with reconstitution near the adductor canal. The popliteal and tibioperoneal vessels were not significantly diseased. The right SFA showed a severe ostial stenosis of nearly 90%. Again, the runoff vessels were not significantly diseased. Because of her severe life-limiting claudication, we attempted PTA of the left SFA. A 6 Fr Ansel guiding catheter (Cook Medical) was advanced from the right common femoral artery. Through a micropuncture modified Seldinger technique, the left popliteal artery was cannulated. Using a sheathless access 4 Fr Glidecath (Terumo Medical) with a Whisper wire (Abbott Vascular), we were able to advance through the SFA retrograde to the ostium of the SFA. The Whisper wire was unable to cross the proximal cap. An Astato wire (Asahi Intecc) was then advanced through the glide catheter and this crossed the proximal cap into the native common femoral artery but we were unable to cross into the graft. The SFA was ballooned with an AngioSculpt balloon (AngioScore) throughout its length. Angiography showed that the wire was subintimal but improved retrograde flow was noted in the left SFA.

At this point the retrograde wire was anchored behind the knee and the patient was placed in a supine position. A second Astato wire (Asahi Intecc) was advanced through the Ansel sheath (Cook Medical) and a glide catheter to the level of the proximal cap. This wire then crossed into the proximal SFA and was easily advanced to the level of the popliteal artery. A 7 mm AngioSculpt balloon (AngioScore) was used to dilate the ostium of the SFA and the rest of the SFA was stented using self-expanding Abbott stents in an overlapping fashion after the popliteal wire was removed. Angiography showed a less than 20% stenosis at the left SFA ostium and no significant stenosis within the SFA proper. Excellent outflow was demonstrated.

This case is an excellent example where commitment to a single approach would not work successfully. The combined retrograde (popliteal) and antegrade approach to this chronic total occlusion of an SFA and aortofemoral bypass anastomosis was necessary to achieve success in this complicated case. The flexibility that the two techniques afforded allowed us to achieve complete revascularization in an otherwise inoperable situation.

Figure 1. Pre-procedure showing the total occlusion.

Figure 2. Popliteal wire going subintimal.

Figure 3. Antegrade wire coming through the graft.

Figure 4. Retrograde wire also going into the subintimal space.

Figure 5. Retrograde wire subintimally and not in the graft.

Figure 6. Popliteal wire and antegrade on top.

Figure 7. Lesion where graft goes into the SFA.

Figure 8. AngioSculpt balloon at the anastomosis of graft of SFA.

Figure 9. Post-procedure.