Utilizing a Combination of Retrograde Tibial Artery Access and Transcollateral Crossing to Treat Multiple Chronic Total Occlusions of the Posterior Tibial and Peroneal Arteries

Disclosure: Dr. George Adams reports he is a consultant for Cook Medical, Daiichi Sankyo,  Lake Region Medical, Volcano, Asahi, Abbott Vascular, CSI, Medtronic, and Terumo. He is a speaker for Abbott Vascular, CSI, Cook Medical, Medtronic, and Spectranetics. He has received research support from Boston Scientific, CloSys, Daiichi Sankyo, Flexible Stenting Solutions, Medtronic, Volcano, and Mercator. Dr. Vinayak Subramanian reports no conflicts of interest regarding the content herein. Orlando Marrero reports he works for Mercator MedSystems and is a consultant for Boston Scientific.

The authors can be contacted via Orlando Marrero, RCIS, MBA, at orlm8597@icloud.com.

Peripheral arterial disease (PAD) affects 8 million Americans.¹ The most severe manifestation of the disease is critical limb ischemia (CLI), characterized by an ankle-brachial index <0.4. Non-healing arterial ulcers in the extremities are a common sign seen in patients with CLI. Non-healing ulcers may lead to gangrene and infections that commonly result in limb amputation. The long-term outlook of these patients is bleak: the five-year mortality rate of patients who undergo limb amputation as a result of peripheral artery disease is 50%.² Restoring blood flow in order to facilitate wound healing efforts can prevent the need for amputation, thereby improving the patient’s long-term health outcome.³ Endovascular revascularization of occluded peripheral arteries is the optimal course of treatment for patients with non-healing ulcers and PAD. 

Despite significant advances in the development of interventional tools, treatment of CLI remains challenging. Chronic total occlusions (CTOs) are a commonly encountered challenge faced by interventionalists. The success rate of treating CTOs ranges from 31-91% and 

largely depends on the skill level of the interventionalist.⁴ Utilizing a combination of exotic techniques such as retrograde access and transcollateral crossing can increase the options available to the interventionalist for treatment of a complex lesion and improve procedural success.^5-8 Herein, we present a case where the use of such exotic techniques allowed for the successful restoration of inline flow to the distal peripheral vasculature in order to improve wound healing of an arterial ulcer on the lateral aspect of the left foot. 

Case report

A 63-year-old male patient with history of coronary heart disease, hypertension, and diabetes mellitus was brought to the catheterization lab due to a non-healing ulcer on the lateral aspect of his foot. To improve wound healing efforts and prevent amputation, the prescribed course of treatment is to restore inline flow in the occluded vessels. 

A diagnostic angiogram of the left lower extremity reveals a chronic total occlusion of the posterior tibial and peroneal arteries (Figure 1). An antegrade approach was attempted and a Runthrough wire (Terumo) with support catheter is advanced to the proximal cap of the CTO.However, because of an inability to cross the CTO from an antegrade approach after attempting with an 18g Approach CTO wire (Cook), 18g Victory wire (Boston Scientific), and 30g Astato wire (Asahi Intecc), retrograde access of the posterior tibial artery at a level below the CTO was performed. An 18g Victory wire was advanced with the support of a Corsair crossing catheter (Asahi Intecc) and the posterior tibial, tibioperoneal (TP) trunk, and popliteal CTO were crossed (Figure 2A). The 18g Victory was switched out for an 18g Approach wire and externalized by threading the retrograde wire into an antegrade angled DAV catheter (Cook Medical) in a flossing fashion (Figure 2B). Subsequent percutaneous transluminal angioplasty (PTA) with a 3x150mm balloon extending from the posterior tibial to the popliteal artery was successful in recanalizing the occluded segment of the artery (Figure 2C). 

PTA of the posterior tibial segment allows the advancement of antegrade tools to open a CTO of the peroneal artery in order to optimize blood flow to the distal vasculature. Due to an inability to cross the CTO from an antegrade position, a transcollateral approach through the geniculate arteries is taken (Figure 3A). A floppy-tipped Scion wire (Asahi Intecc) supported with a Corsair crossing catheter is advanced through the circuitous geniculate collateral channels to the distal cap of the CTO (Figures 3B-C). An 18g Cook CTO wire is used to cross the lesion from a retrograde approach and a 1.5x15mm over-the-wire coronary angioplasty balloon is used to develop a channel in the occluded segment of the peroneal artery. In a wrapping fashion, a second wire from an antegrade approach was placed in the peroneal artery and PTA with a 3x15mm coronary balloon was performed (Figure 4A).

Revascularization of the two CTOs restored inline flow to the distal peripheral vasculature (Figure 4). By enhancing perfusion of the peripheral arteries of the foot, wound healing efforts can be improved and amputation can be prevented, thus improving the patient’s health outcomes. 

Discussion

Patients who undergo amputation due to peripheral arterial disease have a much higher mortality rate and a significant reduction in their quality of life. CLI patients who undergo an amputation have a 5-year mortality of 50%.² Endovascular revascularization is the optimal course of treatment for patients with CLI, due to its short recovery times and potential to preempt amputation.^2,3 Despite significant advances in the development of interventional tools, treatment of severe PAD is challenging due to a variety of factors including long and complex lesions, and CTOs present in the peripheral artery tree.^5-8 Utilization of retrograde access and transcollateral crossing of CTOs are exotic techniques that can allow an interventionalist to treat lesions that are untreatable by conventional techniques. We hope that the success we have had using these techniques in the case herein will encourage more interventionalists to add these techniques to their toolbox of techniques to treat severe cases of PAD. n

References

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