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  • br Introduction Since Reekers and Bolia introduced subintima

    2019-07-01


    Introduction Since Reekers and Bolia introduced subintimal angioplasty, the trans-subintimal route has become the preferred technique to advance the guidewire through a totally occluded and often heavily calcified lesion, especially in the aortoiliac segment. The technical failure was seen in 20–30% of cases, due to an inability to re-enter the true lumen by conventional guidewire and catheter-based subintimal angioplasty technique. Several purpose-built re-entry devices, including the Pioneer catheter (Medtronic, Dublin, Ireland), Outback device (Cordis, Johnson & Johnson, Miami Lakes, Florida, USA), and Frontrunner catheter (Cordis), had been developed with successful re-entry at 90–100%. However, availability, cost, and the lack of user experience limit their implementation. Several alternative techniques to re-enter the true lumen of the distal abdominal Azaserine have also been described, such as by using a coaxial transjugular intrahepatic portosystemic shunt (TIPS) needle, modified trans-septal needle, or metal cannula. As the abdominal aortic puncture of the above-mentioned techniques were all performed simply under fluoroscopic guidance, the procedural safety may have been a concern by many interventionists. In this study, we introduced cone-beam computed tomography (CT) guidance to aid Colapinto needle re-entry into the abdominal aorta in difficult chronic iliac artery occluded lesions.
    Methods
    Results Ten patients (9 male, 1 female; median age, 75 years and range, 45–87 years) were included in this study. Regarding the clinical symptoms of those participating patients, six presented with claudication, three with chronic ulcer, and the remaining one had Buerger\'s disease after bilateral below-knee amputation, with limb coldness. The average occlusion length was 10.2 cm (range, 4–15 cm). According to the Trans-Atlantic Inter-Society Consensus (TASC) II classification, five patients had Class D lesions (occlusion of both common and external iliac artery), and five patients had Class B lesions (isolated common iliac artery occlusion). There were five lesions each on either the left or the right side. The cone-beam CT images showed that the re-entry points of the abdominal aorta were at the 8–10 o\'clock direction in four of the right-sided lesions, the 12 o\'clock direction in the one remaining right-sided lesion, the 2–4 o\'clock direction in four of the left-sided lesions (Fig. 2), and the opposite side of the 9–10 o\'clock direction in the remaining left-sided lesion (Fig. 3). Re-entry with anatomical success was demonstrated angiographically in all 10 patients. No procedure-related complications or 30-day periprocedural mortality were encountered. The median follow-up duration of the 10 patients was 6 months (range, 3–45 months), although three patients were lost to follow-up after the procedure at 3 months, 5 months, and 6 months, respectively. One patient died at 16 months\' follow-up because of malignant lymphoma. The ABI values before percutaneous transluminal angioplasty (PTA) procedure ranged between 0.38 and 0.79 (median: 0.47), then increased to 0.75–1.28 (median: 0.96) within 3 months after the procedure (p = 0.012). Imaging follow-up (> 6 months) was available in six patients (3 by Doppler ultrasound, 2 by CT, and 1 by magnetic resonance). All patients had patency of the stented iliac arteries, without complaints of recurrent clinical symptoms during the follow-up period. The demographic data and clinical outcome of the 10 patients are listed in Table 1.
    Discussion Subintimal angioplasty is now considered to be an ideal alternative for long segmental chronic total occlusion, especially in the aortoiliac segment. Accurate re-entry into the true lumen during subintimal recanalization is the most crucial procedure of the interventional process. The reported overall success rates of transcatheter recanalization of chronic total occlusion (CTO) in the iliac segments using conventional techniques average around 75% (33–89%). However, failed re-entry may further complicate chronic total occlusion by disruption of valuable collateral channels as a result of subintimal dissection.