Trans-Collateral angioplasty for a challenging chronic total occlusion of the tibial vessels: A novel approach to percutaneous revascularization in critical lower limb ischemia

Arterial revascularization by means of percutaneous transluminal angioplasty (PTA) is a mainstay in the management of patients with peripheral artery disease and critical limb ischemia (CLI). However, when employing standard approaches, PTA of below-the-knee arteries may fail in up to 20% of cases. In the present article, we report a novel interventional strategy, the "transcollateral" angioplasty approach, which we successfully employed in a patient with critical lower limb ischemia and a challenging total infrapopliteal occlusion. This technique may probably increase success rates of PTA in very challenging total occlusions of below-the-knee arteries (e.g., those lacking a proximal occlusion stump). The tips pertinent to this case are illustrated, including the need to accurately choose appropriate guidewires and balloons, and the identification of the most appropriate collateral pathway. (C) 2008 Wiley-Liss, Inc.