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A case of chronic total occlusion in popliteal artery recanalized by double snare piercing technique
Hirokazu Miyashita1, Kazuki Tobita2, Syuhei Uchida1
1Department of Cardiology, Heart Center, Shonan Kamakura General Hospital, Okamoto 1370-1, 2478533, Kamakura, Japan.
Insights
A novel double snare piercing technique successfully treated complex femoropopliteal chronic total occlusions (CTO) when standard endovascular therapy failed. This approach offers a new option for challenging cases, achieving long-term symptom relief.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapy
Background:
- Chronic total occlusions (CTO) in femoro-popliteal lesions often require complex endovascular therapy (EVT).
- While bidirectional approaches are useful, guidewire passage remains challenging in some CTO cases.
- This case presents a novel re-entry technique for complex femoro-popliteal CTO.
Purpose of the Study:
- To describe a successful re-entry technique for challenging femoro-popliteal CTO.
- To demonstrate the efficacy of a double snare piercing technique in a complex case.
Main Methods:
- A 79-year-old female with Rutherford category IV intermittent claudication underwent EVT for popliteal CTO.
- Conventional crossing techniques failed; a double snare piercing technique was employed using antegrade and retrograde access.
- A guidewire was externalized, a microcatheter advanced, and the lesion treated with covered and interwoven stents.
Main Results:
- The double snare piercing technique successfully achieved guidewire passage through the complex CTO.
- The patient experienced symptom improvement post-procedure.
- No restenosis was observed at the 2-year follow-up.
Conclusions:
- The double snare piercing technique is a potentially effective method for challenging femoro-popliteal CTO.
- This technique offers a viable solution when conventional methods fail.
Background:
Although majority of cases with chronic total occlusion (CTO) in femoro-popliteal lesion were treated with antegrade approach only, some lesions require alternative approach due to its complexity. Bi-directional approach is useful on endovascular therapy (EVT) for CTO; however guidewire passage through the lesion is impossible in some challenging cases. The present case shows a successful re-entry technique utilizing two snare catheters from an antegrade and retrograde access site (double snare piecing technique).
Case Presentation:
A 79-year-old woman with right leg intermittent claudication (Rutherford category IV), who had undergone unsuccessful EVT for popliteal CTO, required another EVT for the worsening symptom. Following the failed conventional crossing technique (wire knuckle technique, intravascular-ultrasound-guided wiring, and controlled antegrade and retrograde subintimal tracking technique), two snare catheters were placed and the snare loops were pierced by a puncture needle percutaneously. After an 0.014 wire was inserted into the needle, the needle was withdrawn. The wire was pulled from the retrograde side and was externalized. Then, the antegrade snare catheter was pulled and externalized, to make the wire across the lesion. After that, a microcatheter was advanced along the externalized wire from the retrograde side and cross the lesion. The wire was replaced with a new wire, which completely created pull-through system. After the hemostasis by balloon inflation and lesion preparation, this procedure was completed with an endoluminal-covered stent and two inter-woven stents. The re-entry site was covered by the inter-woven stent. Her symptoms improved after the procedure, and the lesion has not developed restenosis at 2-years follow-up.
Conclusions:
This re-entry technique of puncturing two snare loops (double snare piercing technique) might be effective for achieving successful passage through challenging femoropopliteal CTO cases.
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