Superior femoral artery (SFA) disease is the leading cause of peripheral artery disease and claudication. Endovascular interventions in the SFA are quite challenging due to the presence of different biochemical, anatomical, and hemodynamic forces. We present a case of a chronic total occlusion (CTO) of the SFA, which was treated with directional atherectomy and balloon angioplasty.
Material and Methods:
A 62-year old male presented with severe lifestyle-limiting claudication (Rutherford Grade 3). He had severe bilateral discomfort which occurred on walking less than two blocks. A pre intervention ultrasound revealed a complete atherosclerotic occlusion of the right SFA and anterior tibial artery with critical narrowing of the left femoral artery. Angiography revealed a long CTO of the right SFA (TASC D) with distal reconstitution, two-vessel runoff on the right lower extremity run, and critical narrowing of the left distal SFA with two-vessel runoff. Endovascular intervention was planned for the right SFA CTO.
For the intervention on the right SFA, contralateral antegrade access was established via the left common femoral artery, and angiography was done to visualize all the lesions. The left SFA CTO was managed with atherectomy performed by using an Ocelot device (Avinger). A 7 x 320 cm SpiderFX filter (Medtronic) was advanced through the SFA and parked into the popliteal artery. Directional atherectomy was then performed using a 7 French (Fr) Pantheris device (Avinger). Serial balloon angioplasty was performed throughout the length of the SFA using a 6 x 120 mm Chocolate Balloon (Medtronic) and then a 7 x 250 mm Pacific Xtreme balloon (Medtronic). Post-intervention angiography showed improved flow and caliber of the SFA. Left lower extremity intervention is planned for the next sitting to further improve the claudication distance.
Revascularization of peripheral vascular disease continues to evolve towards the use of more aggressive endovascular technique; in this case, we used an Ocelot catheter along with Pantheris device for atherectomy. The Ocelot catheter is an optical coherence tomography (OCT)- equipped CTO crossing catheter that uses real-time OCT guidance for optimal intraluminal recanalization. The CONNECT II study, evaluating the Ocelot catheter, showed a total successful crossing rate of 97% with less radiation and less contrast, but noted that this device has a fairly steep learning curve.