Percutaneous angioplasty of a very long-segment chronic total occlusion of the iliofemoral artery is challenging when it is associated with contralateral iliac artery occlusion. In this case report of peripheral angioplasty, we have tried to simplify the procedure by using a systematic approach. We report a case of peripheral angioplasty in which the patient had chronic total occlusion of the right femoropopliteal with total occlusion of contralateral side of the common femoral artery. The revascularization procedure was successfully completed using the ipsilateral retrograde transpopliteal approach.
Atheromatous chronic total occlusion (CTO) of the iliofemoral artery causes significant symptoms as a result of poor collateral support from the profounda femoris artery due to the diffuse nature of the disease. These lesions are usually categorized as Transatlantic Inter-Society Consensus (TASC) II C and D lesions. Leg pain at rest, a chronic non-healing ulcer, poor healing response to repeated debridement attempts, and amputation of some of the toes are often part of the patient history.1 The preferable treatment approach is surgery, but an alternative approach is endovascular intervention using ipsilateral brachial or retrograde popliteal access when the iliofemoral artery is chronically occluded along with significant disease in the contralateral iliofemoral artery. We report a case of peripheral angioplasty in which the patient had CTO of the right femoropopliteal occlusion with contralateral side total occlusion of the common femoral artery. The revascularization procedure was successfully completed using the ipsilateral retrograde right transpopliteal approach.
A 58-year-old man presented with right lower-extremity claudication at rest with Rutherford grade 4 ischemic atrophy of the right foot despite several attempts at debridement, as well as amputation of the great toe of the right lower limb. He did not have diabetes and did not smoke. The patient underwent peripheral arterial Doppler, which revealed significant atheromatous disease of both lower-limb arteries. Computed tomography (CT) of the abdominal aorta and lower limbs was done with contrast enhancement (Figure 1A), and the juxtarenal aorta and infrarenal aorta had mild disease. Both renal arteries were normal. CT angiogram showed total occlusion of the external iliac artery, common iliac artery, and almost the entire length of the superficial femoral artery (SFA), except at its far distal segment. Ankle brachial index was 0.8 in the left lower limb and 0.4 in the right lower limb. CT angiogram of the left lower extremity revealed the total occlusion of the entire length of the femoral artery except at its distal part with robust collaterals from the profunda femoris artery.
As there was no claudication in the left lower extremity, we planned to revascularize the right lower extremity. The length of the entire diseased segment of the right lower extremity was approximately 40 cm (right common iliac and right SFA), and it was categorized as a type D lesion according to the TASC classification.
The patient did not consent to surgical revascularization but did agree to percutaneous intervention. As this patient had CTO of the left common iliac artery, we preferred to use ipsilateral retrograde popliteal access of the right lower extremity. Brachial or transradial access was avoided because of the very long segment of chronic occlusion of the right common femoral artery and right SFA.
Just prior to the procedure, the patient underwent a peripheral arterial Doppler test. The course of the right popliteal vein and the far distal part of the right SFA were physically marked by the opening of the cap of the 22 gauge intravenous needle by applying firm pressure to its closed end under ultrasound guidance. The patient lay in the prone position with his head toward the C-arm of the x-ray machine to reduce the radiation exposure of the operators. His head was supported by a pillow, and his prone foot was supported with a folded sheet of cloth so that the foot rested at an angle of 20° to the ground at the knee joint.
With aseptic measures, local anesthesia, and proper counseling, an attempt was made to enter the distal SFA using the 18 gauge needle (Cook Medical) via retrograde popliteal access. At the first attempt, the routine 18 gauge needle entered the distal part of the great saphenous vein, which was confirmed by the follow-up of the course of iodinated contrast and Terumo guidewire (Figure 1B), which helped us immediately access the distal SFA. A 6 Fr sheath was introduced into the distal SFA via the popliteal artery. AB The opening pressure waveform was 60 mm Hg. As this patient was already taking clopidogrel, cilastazole, and a statin, a bolus of 5000 IU unfractionated heparin was given.
The entire length of the lesion was crossed retrogradely with the support of the Optitorque diagnostic catheter (Terumo) and exchange-length wire (Terumo). The patient’s abdominal aortic pressure was 148/84 mm Hg. The iliofemoral area was dilated with a 5 × 80 mm Armada balloon (Abbott Vascular). The distal SFA systolic pressure improved to 92 mm Hg because of flow limiting dissection in the iliofemoral area and mild dissection in the distal SFA area (Figure 2). The SFA was almost normal in its middle two-thirds. The ugly dissection in its proximal part was stented using a 7 × 80 mm self-expanding stent (Abbott Vascular) with a very good angiographic result.
However, the systolic pressure did not show significant improvement when the popliteal artery sheath pressure was checked. The blood flow via the side arm of the sheath was very slow. Thrombus was suspected, and we avoided flushing the sheath to prevent possible embolization of the thrombus. The popliteal sheath was exchanged using another 6 Fr sheath, and the removed sheath showed clots when flushed (Figure 3). The patient was given an additional dose of 5000 IU unfractionated heparin, and the popliteal sheath pressure became the same as the abdominal aortic pressure. We left mild distal dissection of the SFA to heal naturally, and there was no further claudication at the follow-up the next month. Triphasic flow was seen on a follow-up arterial Doppler test.
The percutaneous approach to revascularize a chronic iliofemoral occlusion poses unique challenges. The type C or D lesion is difficult to handle by contralateral approach because of insufficient support to guide the catheter, balloon, and guidewire as a result of a lack of coaxial alignment. Although the left brachial approach is a reasonable alternative, the relatively long pathway, as well as the potential for stroke and spasm of the brachial artery and antecubital fossa hematoma, are obstacles. The ipsilateral antegrade was not feasible in our case as a result of the diseased left common femoral artery. Therefore, the ipsilateral retrograde transpopliteal was the preferable approach in our case.2,3
The transpopliteal approach is also useful when antegrade recanalization has failed, in addition to cases with common femoral artery stenosis or occlusion, proximal lesions of the SFA with no stump, severe obesity, tandem iliac, and SFA lesions.2,4 As this technique is associated with several complications such as dissections, vessel ruptures, arteriovenous fistulas, pseudoaneurysm, and hematoma, some precautions are extremely important. The surface anatomy of the popliteal artery (A), popliteal nerve (V), and tibial nerve (N) are in AVN relationship with each other from the midline of the body to the lateral condyle of the femur in the popliteal fossa. The leg should be supported to keep it relaxed to avoid contraction of the thigh muscles, which would obliterate the access site. Ultrasound and digital subtraction angiography may be used for road mapping during puncture. The prone position causes discomfort to patients who are obese or have a sore foot, so the short procedural time with this approach is more comfortable for the patient while also limiting the radiation exposure of the operators. Unless there is significant thrombus burden, as in our case, a bolus of 5000 IU unfractionated heparin is reasonable. Minor dissection that does not limit flow should allow healing on its own; otherwise, the greater number of stents would invite poor long-term outcomes.5
The retrograde popliteal artery approach under periprocedural arterial Doppler guidance can be considered safe and effective in cases of chronic and very long-segment iliofemoral occlusions when they are associated with contralateral iliac artery occlusion.
- Barik R. Missing trees for the forest. Nigerian J Cardiol. 2016;13:152.
- Brountzos EN, Moulakakis KG,Avgerinos ED, et al. Retrograde transpopliteal approach of iliofemoral lesions. Vasc Endovasc Surg. 2011;45:646-650.
- Dumantepe M. Retrograde popliteal access to percutaneous peripheral intervention for chronic total occlusion of superficial femoral arteries. Vasc Endovasc Surg. 2017;51:240-246.
- Schmidt A, Bausback Y, Piorkowski M, et al. Retrograde recanalization technique for use after failed antegrade angioplasty in chronic femoral artery occlusions. J Endovasc Ther. 2012;19:23-29.
- Tsai TT. Missing the forest for the trees? Drug-eluting balloon treatment for infrapopliteal disease. JACC Cardiovasc Interv. 2015;8:1623-1625.