case_images: PMC11419827_01
case_images: Computed tomography angiography and curved planar reconstruction images. (A) Computed tomography angiography showing long segment arterial occlusions on both sides and thoracic aneurysm formation at the aortic arch (arrow). (B) Curved planar reconstruction image of the artery in the right lower extremity, with the arrow pointing to the start and the arrowhead pointing to the end point of the occlusion. (C) Curved planar reconstruction image of the artery on the left lower extremity, with the arrow pointing to the start and the arrowhead pointing to the end point of the occlusion.
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case_images: The infrapopliteal arteries appeared patent, except for the right anterior tibial artery on CTA (Fig. 1A-C). A thoracic arterial aneurysm was seen in the aortic arch (Fig. 1A, arrow); it was classified as stage III based on the Global Limb Anatomic Staging System, with femoropopliteal grade 4 and infrapopliteal grade 0 on both sides.
case_images: Endovascular treatment procedure. (A) A guidewire was inserted after puncturing the posterior tibial artery with extravascular ultrasound (EVUS) guidance. (B) The initial angiogram showed the closed stump of the superficial femoral artery occlusion. (C) An illustration of the intravascular ultrasound (IVUS) guided parallel wiring system representing the IVUS short axis images of the guidewire passing route. (D) External iliac artery. (E) Common femoral artery. (F) Superficial femoral artery. (G) Second guidewire advance through the intraplaque route with IVUS monitoring. (H) Deployment of a SMART self expandable stent in the right external iliac artery. (I) Final angiogram confirming vascular patency and favourable blood flow in the right lower extremity.
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case_images: A guidewire was then advanced into the posterior tibial artery (Fig. 2A) and a Parent Select 5082 (60 cm) guide sheath (MEDIKIT, Tokyo, Japan) was inserted. Initial angiography via the retrograde guide sheath indicated the closed stump of the SFA occlusion (Fig. 2B). When the first guidewire advanced into the subintimal space, a 0.014 inch Halberd guidewire (ASAHI INTECC, Aichi, Japan) was delivered with a Prominent AS microcatheter (Tokai Medical Products, Aichi, Japan) while remaining in the IVUS catheter; Fig. 2C illustrates the IVUS guided parallel wiring system. Subsequently, the Halberd guidewire was manipulated to advance through the intraplaque route by IVUS monitoring (Fig. 2D-G). Intravascular ultrasound showed that most of the occluded lesions were filled with organised thrombi, which suggested that the aetiology was due to a chronic condition following acute limb ischaemia (Fig. 2D-F). After lesion preparation with optimal balloon dilation (EIA: 6.0/60 mm, SFA: 5.0/300 mm), a 8.0/100 mm SMART self expandable stent (Cordis, FL, USA) was deployed in the EIA (Fig. 2H) and the operation was finished with two Ranger drug coated balloon (Boston Scientific, MA, USA) (5.0/200 mm, +6.0/200 mm) dilations from the common femoral artery to the SFA. Good vascular patency and favourable blood flow were confirmed with IVUS and angiography (Fig. 2I).
case_images: Transankle intervention for long segment occlusive disease on the left side. (A) A guidewire was inserted after puncturing the dorsalis pedis artery with extravascular ultrasound guidance. (B) Initial angiography showing the exit of the superficial femoral artery occlusion, representing intravascular ultrasound short axis images of the guidewire passing route. (C) Common iliac artery. (D) Common femoral artery. (E) Superficial femoral artery. (F) Repeated parallel wiring to trace the intraplaque route. (G) Deployment of three SMART stents from the common iliac artery ostium to the external iliac artery. (H) Final angiogram confirming vascular patency and favourable blood flow in the left lower extremity. (I) Confirmation of the intact left dorsalis pedis artery 19 days after the second intervention. (J) Wound healing in the left lower limb 35 days after the second intervention.
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case_images: The left dorsalis pedis artery was punctured under EVUS guidance and a Parent Select 5082 guide sheath was inserted (Fig. 3A and B). The procedures were similar to those performed on the right side. The guidewire was passed retrogradely through the long segment occlusion from the distal SFA to the ostial CIA, all in the intraplaque route (Fig. 3C-F). After lesion preparation with optimal balloon dilation (EIA: 5.0/40 mm, SFA: 6.0/300 mm), three SMART self expandable stents (8.0/60 mm, +10.0/40 mm, +10.0/60 mm) were deployed from the ostial CIA to the EIA (Fig. 3G). Good vascular patency and favourable blood flow were confirmed with IVUS and angiography (Fig. 3H). Nineteen days after the second EVT session, the lower extremity angiography was checked when conducting coronary intervention from the upper extremity; it confirmed that the punctured dorsalis pedis artery was patent (Fig. 3I). The persisting pain in the right lower limb disappeared, and the wound healed favourably in the left lower limb 35 days after the second EVT session (Fig. 3J).