case_images: PMC7273553_01
case_images: Diagnostic angiography demonstrating (a) reconstitution of left common femoral artery stent (top arrow) with stent in failed femoral-femoral bypass (bottom arrow) and (b) flush occlusion of left common iliac artery (arrow).
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case_images: Upon catheterization, angiography confirmed an occluded left CIA with reconstitution at the common femoral artery (CFA) (Figure 1(a)). Given the ostial flush occlusion of the left CIA (Figure 1(b)) in the setting of an identified absence of the radial artery, a decision was made to pursue ulnar artery access along with tibioperoneal access to perform endovascular revascularization.
case_images: Access approaches with (a) sheath advanced from ulnar artery to distal aorta (top arrow) with retrograde dissection of proximal cap of occlusion (bottom arrow), (b) left peroneal artery access, and (c) subintimal advancement into the common femoral artery (arrow).
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case_images: With administration of an antispasmodic cocktail of 100 microg of nitroglycerin, 2.5 mg of verapamil, and unfractionated heparin (5000 U, intra-arterial), left ulnar artery access was obtained and a 6F 119 cm R2P Slender Glide sheath (Terumo, Somerset, NJ) was advanced to the distal aorta (Figure 2(a)). Upon ultrasound examination, the left distal anterior tibial (AT) artery and left posterior tibial (PT) artery were occluded so peroneal artery access was obtained (Figure 2(b)) and a 4F sheath (Terumo, Somerset, NJ) was placed. From the antegrade approach, a 0.035'' Straight Stiff glidewire (Terumo, Somerset, NJ) was advanced in the subintimal plane around the occlusion and into the CFA (Figure 2(c)). Via the peroneal access, a 0.018'' V18 wire (Boston Scientific) was used to subintimally dissect around the distal cap of the occlusion and into the CFA (Figure 2(a) and (c)).
case_images: Controlled antegrade and retrograde tracking and dissection by (a) retrograde balloon inflation (from peroneal artery access) with (b) snare and externalization of advanced guidewire by antegrade wiring (from ulnar artery access). (c) Subsequent aortic bifurcation reconstruction by kissing balloon inflations and (d) absolute Pro SE stent in left external iliac artery.
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case_images: Tracking) technique was performed where a 6.0 mm x 80 mm Sterling OTW balloon (Boston Scientific, Somerset, NJ) was advanced into the retrograde dissection plane (Figure 3(a)). Retrograde balloon inflation was performed and the stiff Glidewire was now able to re-enter into the true lumen from above. The wire was then snared and externalized out the foot creating a continuous true lumen from the ulnar to the peroneal (Figure 3(b)). To reconstruct the aortic bifurcation, kissing balloon inflations (6.0 mm x 80 mm Sterling OTW (Boston Scientific) and 6.0 mm x 200 mm Metacross (Terumo, Somerset, NJ)) were performed (Figure 3(c)) from the antegrade and retrograde approaches. An Omnilink 10 mm x 59 mm balloon expandable stent (Abbott Vascular, Santa Clara, CA) was deployed in the ostial left CIA followed by an Absolute Pro SE 8 mm x 60 mm self-expanding stent (Abbott Vascular, Santa Clara, CA) in the left EIA (Figure 3(d)).
case_images: (a) Final angiographic result demonstrating revascularization of left common iliac artery and external iliac artery with (b) patent popliteal artery with no downstream embolization visualized.
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case_images: The final angiographic result (Figure 4(a)) showed excellent flow with no complications during the procedure.