N.K.

We report on a 69-year-old male with a severe claudication. He has a history of hypertension and idiopathic ventricular fibrillation. He felt right leg pain even on light exertion. Right leg pain was getting worse and couldn’t live his daily life, so he visited emergency department in our hospital. At that time, his right foot was colder than the other one.

His right ankle-brachial index (ABI) couldn’t be measured because his pulse volume waveform was flat in his right leg, and contrast-enhanced computed tomography discovered total occlusion in his right superficial femoral artery (SFA) and tibioperoneal trunk.

We punctured left common femoral artery and performed contralateral crossover approach. We inserted 6Fr guiding-sheath and control angiography showed  total occlusion from SFA proximal to distal, and tibioperoneal trunk.

We advanced a 10g 0.014-inch guidewire (Jupiter X, Japan) into the CTO. Next, we advanced intravascular ultrasound (IVUS), and IVUS showed the guidewire partially ran through the subintimal route, so we performed IVUS-guided re-wiring with 40 g 0.014-inch guidewire (Astato XS9-40, Japan). We succeeded to cross the guidewire into all intraplaque route, and we performed dilation. After that, IVUS showed a part of plaque peeled off there. We aspirated the plaque there by 8Fr thrombus aspiration catheter.However, the angiography after aspiration showed no flow by distal embolization in popliteal artery (Pop A). We tried to aspirate embolus by 8Fr thrombus aspiration catheter repeatedly, but it was unsuccessful. IVUS showed the lumen of Pop A was occupied with the organized thrombus. Based on the IVUS findings, we determined that bailout was difficult with an aspiration catheter or balloon dilation. Therefore, we decided to use myocardial biopsy forceps under the guidance of IVUS to remove the thrombus. We inserted a 6Fr, 25 cm sheath in the right CFA ipsilateral antegradely and inserted myocardial biopsy forceps with a slightly bent tip. However, IVUS showed the shape of embolus was difficult to catch, so we tried to modify the shape of thrombus by dilation of scoring balloon. After that, we were able to catch the embolus by myocardial biopsy forceps with IVUS guidance. IVUS and the angiography showed that there was no embolus in the Pop A and blood flow was dramatically improved.
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After EVT, his severe claudication disappeared completely and value of  ABI became 0.94.We sometimes suffer from distal embolization. At that time, we sometimes catch it by endomyocardial biopsy forceps by angiography guided. However, whether we can catch it is by chance. In this case, by using navigation by IVUS, we caught the embolus more reliably. Now we report our novel bailout technique of EVT when distal embolism happens.