Intravascular ultrasound-guided reentry wiring with tip-detection technique for chronic total occlusion of lower extremity artery disease

BackgroundEndovascular therapy is an effective method for revascularization in lower extremity artery disease, but treating chronic total occlusion (CTO) remains challenging. This is particularly true for patients with severe calcification, poor run-off in below-the-knee arteries, or limited access sites, where even guidewire (GW) passage can be difficult and bidirectional approaches are often not feasible. The tip-detection (TD) method has been reported as a useful technique in coronary artery CTO interventions, allowing real-time visualization of the GW tip direction. Here, we applied the TD technique for peripheral CTO intervention.Case presentationCase 1 involved a 71-year-old man with a right toe ulcer. Angiography revealed total occlusion from the right anterior tibial artery (ATA) to the proximal dorsalis pedis artery. While attempting IVUS-guided parallel wiring, the GW could not advance through the intraplaque route because of severe calcification. We intentionally advanced the GW and IVUS into the subintimal space of the ATA to bypass the calcified lesion and performed IVUS-guided reentry using the TD technique in the distal ATA, where calcification was less severe. The second GW successfully passed through the intraplaque of the distal ATA and into the true lumen of the dorsalis pedis artery. Case 2 involved a 60-year-old man with bilateral intermittent claudication. Angiography revealed severe stenosis of the right common iliac artery (CIA) and CTO of the left CIA. Because of anatomical limitations and access site challenges, the antegrade approach for the left CIA was unsuccessful, and retrograde intraluminal wiring was difficult because of flexion and calcification. We advanced the GW and IVUS into the subintimal space and performed IVUS-guided reentry using the TD technique to access the true lumen of the proximal CIA. Finally, bilateral VBX stent grafts were implanted using the kissing stent technique.ConclusionsIVUS-guided reentry wiring with the TD technique may offer a useful solution for passing complex peripheral CTO lesions in cases where only a uni-directional approach is feasible.