Inframalleolar thrice distal puncture in a single endovascular treatment session for successful revascularization
Issei Ota1, Tetsuya Nomura2, Kenshi Ono1
1Department of Cardiovascular Medicine, Kyoto Chubu Medical Center, 25, Yagi-Ueno, Yagi-cho, Nantan City, Kyoto, 629-0197, Japan.
Insights
This study introduces a novel triple distal puncture technique for endovascular treatment (EVT) in complex infrapopliteal arterial disease. This advanced retrograde approach significantly improves revascularization success rates in challenging chronic limb-threatening ischemia cases.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Treatment
Background:
- Chronic limb-threatening ischemia (CLTI) frequently involves complex infrapopliteal arterial disease, posing significant treatment challenges.
- Retrograde access is a crucial technique in endovascular treatment (EVT) for guidewire crossing and device delivery in these challenging lesions.
- No prior EVT case has reported the use of inframalleolar thrice distal puncture in a single session.
Purpose of the Study:
- To describe a novel endovascular treatment strategy utilizing triple distal puncture for complex infrapopliteal arterial disease.
- To demonstrate the feasibility and effectiveness of an advanced retrograde approach in a challenging CLTI case.
Main Methods:
- A 60-year-old CLTI patient with WIfI grade 3 underwent EVT for occluded dorsal and posterior tibial arteries.
- A retrograde approach via the lateral plantar artery successfully treated the posterior tibial artery occlusion.
- Triple distal puncture (first dorsal metatarsal artery, distal anterior tibial artery) was employed to achieve retrograde guidewire and microcatheter access for dorsal artery occlusion, utilizing a 'needle rendezvous' technique for guidewire externalization and balloon angioplasty.
Main Results:
- Successful revascularization of both dorsal and posterior tibial arteries was achieved.
- The novel triple distal puncture technique facilitated successful guidewire crossing and device delivery.
- Complete hemostasis was achieved at all puncture sites, and favorable vascular patency and blood flow were confirmed post-procedure.
Conclusions:
- The described triple distal puncture technique is a viable and effective strategy for complex infrapopliteal arterial occlusions in EVT.
- This advanced retrograde approach can significantly increase revascularization success rates in challenging CLTI cases.
- Effective utilization of retrograde access, even with multiple distal punctures, is key to managing complex infrapopliteal disease.
Background:
Most patients with chronic limb-threatening ischemia (CLTI) have infrapopliteal arterial disease, which are often challenging to treat. In endovascular treatment (EVT) for these complex lesions, establishing retrograde access is an essential option not only for guidewire crossing but also for device delivery. However, no EVT case has yet been reported requiring inframalleolar thrice distal puncture in a single EVT session so far.
Case Presentation:
A 60-year-old CLTI patient with grade 3 Wound, Ischemia and foot Infection (WIfI) classification underwent EVT for occluded dorsal artery and posterior tibial artery. First, we conducted successful balloon angioplasty of the posterior tibial artery by establishing a retrograde approach via the lateral plantar artery. To treat the occlusion of the dorsal artery, we punctured the first dorsal metatarsal artery, and retrogradely advanced a guidewire to the dorsal artery occlusion; however, the microcatheter could not follow the guidewire. Therefore, we punctured the occluded distal anterior tibial artery and introduced the retrograde guidewire into the puncture needle. After guidewire externalization, we pulled up the retrograde microcatheter into the occlusion of dorsal artery using the "balloon deployment using forcible manner" technique. Thereafter, we were able to advance the antegrade guidewire into the retrograde microcatheter. After guidewire externalization, an antegrade balloon catheter was delivered and inflated for the purpose of dorsal artery dilation and hemostasis at the "needle rendezvous" point. Consecutively, balloon dilation was performed for puncture site hemostasis of the first dorsal metatarsal artery and complete hemostasis was achieved. Finally, we confirmed good vascular patency and favorable blood flow. After revascularization, transmetatarsal amputation was performed and the wound healed favorably.
Conclusions:
We can markedly increase the success rate of revascularization by effectively utilizing the retrograde approach in EVT for complex chronic total occlusions in infrapopliteal arterial diseases.
