Korean Circ J.  2013 Apr;43(4):261-264. 10.4070/kcj.2013.43.4.261.

Three-Dimensional Angiography-Guided Percutaneous Transluminal Angioplasty for Distal Aorta and Bi-Iliac Chronic Total Occlusion

• Kim DH
• Rha SW
• Kook H
• Kim W
• Lee SK
• Oh SK
• Choi CU
• Oh DJ

• KMID: 2224949
• DOI: http://doi.org/10.4070/kcj.2013.43.4.261

Abstract

Percutaneous recanalization of chronic total occlusions (CTOs) in peripheral arteries, especially TASC D classification including the distal aorta and both iliac arteries is still technically challenging. The conventional technique using standard guidewires and catheters guided by computed tomography and angiography can achieve a limited initial success, depending on lesion characteristics and operator's experience. A special imaging technique using 3-dimensional rotational angiography and spatio-temporal reconstruction with endoview for a better examination of the proximal stump, exact obstruction location, and distal stump direction in a stumpless lesion can be indispensable for successful intervention. We report a successful revascularization case of stumpless distal aorta and bi-iliac CTO guided by this specialized imaging technique.

Keyword

Percutaneous transluminal angioplasty; Aorta, abdominal; Occulusion; Angiography; Imaging, three-dimensional

MeSH Terms

Angiography
Angioplasty
Aorta
Aorta, Abdominal
Arteries
Catheters
Iliac Artery
Imaging, Three-Dimensional

Figure

• 

  Fig. 1 Preprocedural CT angiographic findings. Preprocedural CT angiography showed that there was total occlusion from the distal aorta to both iliac arteries. Inferior mesenteric artery from the distal abdominal aorta (black arrow) was hypertrophied and prominent. But there was no angiographically visible stump in the distal aorta at the inferior mesenteric artery ostium level (white arrow).

• 

  Fig. 2 Invasive 3D angiographic image of pre-stenting. A: 3D angiographic image. B: endoview at the distal aorta total occlusion level from 3D reconstruction image. A virtual line was drawn from the distal abdominal aorta to right iliac artery (dot line). There was a suspicious micro-channel from the distal abdominal aorta to right iliac artery (transparent arrow). This micro-channel was not seen by previous CT angiography. There was a visible inferior mesenteric artery from distal aorta (black arrow). 3D: three-dimensional.

• 

  Fig. 3 Successful complete revascularization and the final results. A: bilateral kissing wiring using 035 soft Terumo wires under the 5 Fr multipurpose catheter support by subintimal tracking from distal aorta to external iliac artery. B: predilation in right iliac artery after successful kissing wiring. C: bilateral kissing stenting using two self-expanding nitinol stents from distal aorta to both iliac arteries. D: postprocedural angiography.

Reference

1. Gallagher KA, Meltzer AJ, Ravin RA, et al. Endovascular management as first therapy for chronic total occlusion of the lower extremity arteries: comparison of balloon angioplasty, stenting, and directional atherectomy. J Endovasc Ther. 2011. 18:624–637.

2. van der Heijden FH, Eikelboom BC, Banga JD, Mali WP. Management of superficial femoral artery occlusive disease. Br J Surg. 1993. 80:959–963.

3. Al-Ameri H, Shin V, Mayeda GS, et al. Peripheral chronic total occlusions treated with subintimal angioplasty and a true lumen re-entry device. J Invasive Cardiol. 2009. 21:468–472.

4. Lee JB, Chang SG, Kim SY, et al. Assessment of three dimensional quantitative coronary analysis by using rotational angiography for measurement of vessel length and diameter. Int J Cardiovasc Imaging. 2012. 28:1627–1634.

5. Kawasaki D, Tsujino T, Fujii K, Masutani M, Ohyanagi M, Masuyama T. Novel use of ultrasound guidance for recanalization of iliac, femoral, and popliteal arteries. Catheter Cardiovasc Interv. 2008. 71:727–733.

6. Kawarada O, Yokoi Y, Takemoto K. Practical use of duplex echo-guided recanalization of chronic total occlusion in the iliac artery. J Vasc Surg. 2010. 52:475–478.

7. Dvir D, Assali A, Kornowski R. Percutaneous coronary intervention for chronic total occlusion: novel 3-dimensional imaging and quantitative analysis. Catheter Cardiovasc Interv. 2008. 71:784–789.

8. Pannu N, Wiebe N, Tonelli M. Alberta Kidney Disease Network. Prophylaxis strategies for contrast-induced nephropathy. JAMA. 2006. 295:2765–2779.