E-Science Station

HK

  The patient was a 76 years old male who had a had a history of Buerger’s disease for about 40 years.  In his 30s, he was diagnosed and treated as Buerger’s disease. At that time, bypass surgery and toes amputation were performed (details unknown). Then, he had been in stable claudication. This time, he was referred to our hospital because of bilateral toe ulcers and severe leg pain. In physical findings, there were multiple necrotic ulcers in bilateral toes.

  The ABI and SPP values were extremely low in both feet, especially in the right side.   Computed tomography angiography images before treatment showed a focal stenosis in the right external iliac artery. Further, in the right lower limb, the superficial femoral artery (SFA) was totally occluded from its proximal part to inflapopliteal arteries. Only peroneal and anterior tibial arteries could be identified partially. In the left side, the SFA was occluded from its origin to mid portion. 

I planned two phased treatment meaning that I treat the right iliac artery and the left SFA from right groin approach in first session, and next treat the infrainguinal lesions in the right side in second session.
left SFA.mov
right SFA.mov

In first session, I implanted a self-expandable stent in the right iliac artery, and, next treated the chronic total occlusion (CTO) of the left SFA. In the CTO lesion, I advanced the 0.014-inch guidewire intraluminaly with IVUS guidance. I dilated two DCB catheters after successful guidewire crossing, and final angiography showed favorable flow in the left SFA.Five days after first endovascular treatment (EVT), I performed staged EVT for the right lower limb. I first started antegrade wiring from ipsilateral gwoin approach. But, in the popliteal artery, I could not advance the guidewire intraluminaly. Therfore, I decided to add retrograde approach. I punctured the mid portion of the peroneal artery under angiography guidance. A hydrophilic polymer jacket guidewire was inserted carefully from the peroneal artery, and microcatheter was advanced through the guidewire. I manipulated the retrograde guidewire with kissing wiring manner, and, the retrograde guidewire was advanced into the antegrade guiding catheter. I dilated the CTO lesion with a 3.0-mm balloon catheter after externalization. Finally, we used 3 DCB catheters in the SFA and popliteal artery. Final angiography after DCB dilatation revealed excellent flow in the right femoropopliteal artery.
left final 1.mov
right final 1.mov
PA puncture.mov

Because many lesions of Buerger’s disease are inappropriate for stenting and shrinkage vessels, intraluminal wiring using IVUS may be important and useful.Peroneal artery puncture is useful option to add retrograde approach to treat complex CTO lesion, especially in cases that we cannot puncture tibial arteries.Contemporary endovascular treatment using IVUS guidance may be one of the therapeutic options for Buerger’s disease even in patients with prolonged course.