Author + information
- Received January 25, 2016
- Accepted January 29, 2016
- Published online May 9, 2016.
- Keiko Shimamoto, MD,
- Osami Kawarada, MD, PhD∗ (, )
- Koichiro Harada, MD, PhD,
- Teruo Noguchi, MD, PhD,
- Hisao Ogawa, MD, PhD and
- Satoshi Yasuda, MD, PhD
- ↵∗Reprint request and correspondence:
Dr. Osami Kawarada, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan.
The retrograde approach was first used for coronary chronic total occlusions (CTOs) with saphenous vein grafts (1). Recently, collateral vessels have become access points for the retrograde approach in CTO intervention, in the periphery as well as in the coronary artery (2,3). The combination of a saphenous vein graft and a collateral vessel might increase the performance of the retrograde approach.
An ischemic ulcer on the left second toe developed in an 82-year-old diabetic man on hemodialysis with a history of a redo distal bypass for total occlusions in the crural arteries. At another hospital, diagnostic angiography revealed total occlusion of the common plantar artery despite a patent distal bypass. When an attempt to recanalize the occlusion in the common plantar artery was unsuccessful, the patient was referred to our hospital for further consideration of endovascular therapy. Our angiography identified a collateral vessel from the posterior tibial artery (PTA), distal to the bypass, to the distal peroneal artery (Figures 1A and 1B). Selective injection of contrast from a microcatheter in the collateral vessel confirmed that the distal end of the CTO was in the peroneal artery (Figure 1C). We decided to recanalize the CTO in the peroneal artery using a retrograde approach via the distal bypass–PTA collateral vessel to improve blood flow to the foot.
Retrograde advancement of a 0.014-inch hydrophilic guidewire supported by a microcatheter and the CART (controlled antegrade and retrograde tracking) technique facilitated subsequent antegrade crossing and balloon dilation (Figure 2). The final angiography demonstrated establishment of straight-line flow in the peroneal artery (Figure 3). The skin perfusion pressure in the left foot increased from 20 to 44 mm Hg, suggesting a high likelihood of wound healing (4).
The combination of a saphenous vein graft and a collateral vessel could provide a novel retrograde approach for the treatment of infrapopliteal CTOs in patients with a history of distal bypass.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 25, 2016.
- Accepted January 29, 2016.
- American College of Cardiology Foundation
- Okamura A.,
- Yamane M.,
- Muto M.,
- et al.
- Kawarada O.,
- Sakamoto S.,
- Harada K.,
- Ishihara M.,
- Yasuda S.,
- Ogawa H.