Treating a CTO of the SFA Using Auryon Laser Atherectomy in a CLTI Patient

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Nader Chadda, MD, FACC, FSCAI; IIyas Chadda, Pre-Medical Student
Hudson Heart & Vascular Hudson, Florida

Disclosure: Dr. Chadda and IIyas Chadda report no confl icts of interest regarding the content herein.

The authors can be contacted via Dr. Nader Chadda at nader.chadda@gmail.com.

History
The patient is a 77-year-old man with diabetes mellitus, congestive heart failure, and abdominal aortic aneurysm status post repair with stent graft placement, who has been suffering from bilateral foot wounds that have been nonhealing. The wounds have been present for more than six months. The patient has also been experiencing lifestyle-limiting bilateral leg and foot pain occurring at rest and with minimal ambulation for more than six months.

A recent arterial duplex ultrasound of the lower extremities was abnormal, demonstrating monophasic waveforms indicative of a total occlusion of the right superficial femoral artery (SFA). In addition, the arterial duplex ultrasound demonstrated a significant distal left SFA stenosis. The decision was made to proceed with lower extremity angiography and possible intervention.

Interventional Procedure  
After injecting 2% lidocaine solution into the left groin, a micropuncture system was used in a modified Salinger technique to obtain intravenous-arterial access. A J-wire was inserted through the micropuncture sheath and advanced up to the lower aorta. The micropuncture sheath was removed and replaced by a 5 French (F) sheath. A  universal flush catheter was advanced to the level of L1. Abdominal angiography with nonselective renal imaging was performed. After reviewing the images, the catheter was withdrawn to the level of L3. Abdominal angiography with bilateral lower extremity runoff was performed. Due to the aortic stent graft, we were unable to cross over the aortoiliac bifurcation. We obtained right common femoral arterial access, using ultrasound to place a 5F sheath in an antegrade manner. We advanced a Supra Core wire (Abbott) into the total occlusion and the upsized sheath over the Supra Core wire to a 6F, 45 cm Cook sheath. A Glidewire glide catheter (Terumo Interventional Systems) technique was used to traverse the occluded right SFA. The true lumen was reentered distally. Selective angiography confirmed an intraluminal wire position. We exchanged for an .014-inch wire. Laser atherectomy using the 1.5 mm Auryon system (AngioDynamics) was performed in the proximal, mid, and distal right SFA. Several passes were made with the atherectomy catheter on fluency levels of both 50 and 60 mJ/mm², followed by balloon angioplasty with a 6 mm x 150 mm balloon.

Several prolonged balloon inflations of the proximal, mid, and distal right SFA were performed. There was a residual, >50% stenosis and flow- limiting dissection, so a 6 mm x 200 mm nitinol stent was deployed in the distal right SFA. A 6 mm x 120 mm nitinol stent was deployed proximal to the first stent. The stents were post-dilated with a 6 mm x 100 mm balloon. Selective angiography showed an excellent result. There was no dissection, no thrombus, and improved distal runoff. At that point, all catheters and wires were removed. An Angio-Seal device (Terumo Interventional Systems) was used for closure of the right common femoral arteriotomy site. A ProGlide device (Abbott) was used for closure of the left common femoral arteriotomy site.
The patient followed up with podiatry and underwent hyperbaric therapy for the right foot wound. After several months, he demonstrated complete wound healing.