Selected TechniqueA Fine Needle Recanalization Technique for Iliac Artery Occlusions in Endovascular Surgery
Introduction
Endovascular management of aortoiliac occlusive disease (AIOD) has become established as the first-line treatment option with the blooming evolution in technology of various devices and ever increasing clinical expertise which has maximized technical success and patency.1 Endovascular therapy is associated with lower complication rates, shorter length of hospital stay, and lower economic costs when compared to open surgery.2 Research has now shifted to consider advancement in endovascular intervention for complex AIOD.3, 4, 5
Chronic total occlusions (CTO) in AOID sometimes pose a challenge, with regard to crossing the lesion safely and re-entering the true lumen. Failure rate for recanalization can be up to 25%.6, 7 Conventional techniques for treating CTO include probing the lesion using a range of catheters and wires with various mechanical properties, approaching the lesion from the retrograde and anterograde directions and purposeful subintimal crossing of the lesion followed by reentry into the true lumen.8
A number of devices designed for crossing CTO have emerged over recent years including the commercial reentry devices (CRD) such as the Frontrunner® catheter (Cordis, CA, controlled blunt micro-dissection), the Outback® catheter (Cordis, CA, fluroscopically guided true lumen reentry device), the Pioneer® reentry device (Medtronic Inc, MN, intravascular ultrasound guided), and the true lumen crossing device, the CROSSER® system (BARD, GA, ultrasonic vibrational dissection).9, 10, 11, 12 These devices, however, are expensive and do not guarantee technical success, diminishing the cost-effectiveness of the endovascular procedure.13
Sharafuddin et al. reported their endovascular experience of 112 iliofemoral CTO describing a range of strategies including a brief description of an “aggressive” sharp recanalization technique using a “home-made directional sharp needle”.8 This was attempted in 11 limbs following failure of conventional methods with a technical success rate of 82% and no major complications. Similar techniques have been applied in other clinical settings, such as for central venous occlusions, renal access, and iliac venous occlusions.14, 15, 16, 17
Section snippets
Methods
A retrospective review of a prospectively collected database of cases employing the fine needle recanalization (FNR) technique at a tertiary public hospital in Australia was performed. Eleven limbs in 11 patients were identified since 2011. Eight patients had CTO in the common iliac artery (CIA), 2 in the external iliac artery, and 1 involved both of these vessels.
Techniques
The technique is indicated when standard wire and catheter recanalization techniques via antegrade and retrograde approaches fail (Fig. 1). Typically, the procedures were conducted using local anesthesia with or without sedation. Bilateral femoral retrograde access was obtained with a 6F sheath (ipsilateral) (23 cm Brite Tip® Sheath; Cordis, CA) and a 5F sheath (contralateral) (16 cm Glidesheath®; Terumo). A 4Fr Omniflush catheter (Angiodynamics Inc, NY) was introduced into the distal aorta via
Results
Mean age of the 11 patients was 65 ± 12.6 years with a male to female ratio of 4.5:1. Patient comorbidities represented a strong predilection for atherosclerotic risk factors and concomitant cardiac disease (Table I).
FNR was successful in 10 patients (91%). Nine patients failed standard catheter and guidewire techniques, and 1 patient had had a previous failed attempt with a CRD, (CROSSER system [BARD, GA]). In 1 case, FNR failed, but treatment was successful with a CRD, (Outback catheter
Discussion
Endovascular treatment of AIOD has become more advanced, varied, and successful in recent years. A recent study reported 2-year primary patency rates of 94.9% and 88.4% for TASC C and D lesions, respectively.19 CTO in AIOD pose particular challenges to the endovascular approach, with failure most commonly occurring due to difficulty in regaining entry to the true lumen after the lesion has been crossed.20 Our series described the sharp recanalization technique to be effective and safe with a
Conclusion
FNR is a safe and successful means for crossing CTO in AIOD when conventional methods have failed. It benefits from its simplicity, low profile, low cost, and wide availability.
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Cited by (1)
Midterm Results of Endovascular Treatment for Complete Iliac Axis Occlusions Using Covered Stents
2020, Annals of Vascular SurgeryCitation Excerpt :In our series, few cases required a retrograde approach after antegrade crossing was deemed unfeasible, and only one précised the use of a re-entry device. However, other reports favor a retrograde approach, with30,31 or without the aid of re-entry devices.3,6,21 A retrograde recanalization has been told to be especially useful to cross over occluded stents.30
Present address of D.R.A.C. is Monash Health, 246 Clayton Rd, Clayton, Melbourne. VIC 3168. Australia.
The corresponding author is not in recipient of a research grant.
The authors declare no conflicts of interest to disclose.