Total Across Catheter in Chronic Infrapopliteal CTO

By Ajay Mhatre, MD; Moses De Graft-Johnson, MD

Capital Regional Medical Center, Tallahassee, FL

We present a case of a 68-year-old female with a prior history of ischemic cardiomyopathy and history of severe peripheral vascular disease. She has recently undergone a transmetatarsal amputation (TMA) on the right foot as she presented to the hospital with gangrene of the 2nd through 5th digits on the right foot. A few weeks earlier we had performed an intervention to a chronic total occlusion (CTO) of the distal superficial femoral artery (SFA) and popliteal to help facilitate TMA healing. After establishing inline flow through the SFA and popliteal, we performed infra popliteal angiogram (Figure 1). She was found to have extensive infrapopliteal disease with a patent anterior tibial vessel with occluded tibioperoneal (TP) trunk. 

Due to her underlying cardiomyopathy and elevated creatinine of 1.7, we elected to bring her back for infrapopliteal intervention.Access was gained in the left common femoral artery and then we then placed a 55 cm 6 Fr sheath (Cook Medical) up and over into the distal SFA. Next with the aid of the Total Across support catheter (Medtronic), we were able to traverse the sub total occlusion with wire escalation (Figure 2).

During the interventional procedure, first an 0.014" Command wire (Abbott Vascular) was used and then an extra support Whisper wire (Abbott) and finally a Winn 80 Wire (Abbott) was able to traverse the CTO. We were able to confirm the catheter was intravascular by injecting through the catheter as we traversed the CTO (Figure 3).

We were able to traverse and open the peroneal artery. It was ballooned with a 2 mm x 200 mm balloon (Medtronic). Post balloon angiography of the leg showed excellent 2-vessel flow into the foot from the anterior tibial and peroneal arteries (Figure 4). There was also brisk collateral flow into the foot including retrograde collateral flow into the distal posterior tibial through the pedal arch.

She has continued to receive hyperbaric wound care and regular follow-up with a wound specialist. She is doing well and her foot continues to heal.