[MP-14] A case of the very long CTO from the ostium of SFA to the distal end of tibioperoneal trunk treated by the two step intervention with balloon angioplasty alone
[Current history] A 64-year-old man presented with intermittent claudication. His right ankle-brachial index (ABI) was reduced to 0.39. Ultrasonography and computed tomography angiography confirmed the presence of a long chronic total occlusion (CTO) from the ostium of superficial femoral artery (SFA) to the distal end of tibioperoneal trunk. Claudication worsened after 4 months of conservative treatment. He decided to undergo the endovascular treatment (EVT).
[Treatment course] A 6 Fr side hole sheath was inserted at ipsilateral femoral artery. The guidewire was advanced into the CTO with intravascular ultrasound (IVUS) guided wiring and subintimal contrast angiography (SUICA). The guidewire was successfully crossed the true lumen and we performed balloon angioplasty with a 4 mm balloon catheter. Angiography showed antegrade blood flow, but the lesion was not well expanded. We enlarged size of the balloon with 6mm, but post dilatation angiography showed absence of blood flow. The IVUS revealed the major dissection and/or organized thrombus. We performed a long inflation angioplasty with a 4mm balloon catheter, and final angiography showed antegrade blood flow again. We prescribed anticoagulant therapy after EVT. His ABI was improved to 0.91, but 2 months later reduced to 0.68. Second EVT was performed. Angiography showed restenosis lesion in the popliteal artery and distal SFA. We dilated the popliteal lesion with a 5mm cutting-balloon catheter and a 5mm drug-coated balloon. Next we dilated the SFA lesion with a 6mm balloon-catheter and a 6mm drug-coated balloon. Final angiography showed an adequate expansion.
[Consideration] For the first EVT, we aimed to maintain blood flow by the small balloon angioplasty. As a result, the organized thrombus was dissolved with the anticoagulant therapy. For the second EVT, the CTO lesion became as simple, so it could be treated with balloon angioplasty only. We reported as one method of treatment of long CTO.
[Treatment course] A 6 Fr side hole sheath was inserted at ipsilateral femoral artery. The guidewire was advanced into the CTO with intravascular ultrasound (IVUS) guided wiring and subintimal contrast angiography (SUICA). The guidewire was successfully crossed the true lumen and we performed balloon angioplasty with a 4 mm balloon catheter. Angiography showed antegrade blood flow, but the lesion was not well expanded. We enlarged size of the balloon with 6mm, but post dilatation angiography showed absence of blood flow. The IVUS revealed the major dissection and/or organized thrombus. We performed a long inflation angioplasty with a 4mm balloon catheter, and final angiography showed antegrade blood flow again. We prescribed anticoagulant therapy after EVT. His ABI was improved to 0.91, but 2 months later reduced to 0.68. Second EVT was performed. Angiography showed restenosis lesion in the popliteal artery and distal SFA. We dilated the popliteal lesion with a 5mm cutting-balloon catheter and a 5mm drug-coated balloon. Next we dilated the SFA lesion with a 6mm balloon-catheter and a 6mm drug-coated balloon. Final angiography showed an adequate expansion.
[Consideration] For the first EVT, we aimed to maintain blood flow by the small balloon angioplasty. As a result, the organized thrombus was dissolved with the anticoagulant therapy. For the second EVT, the CTO lesion became as simple, so it could be treated with balloon angioplasty only. We reported as one method of treatment of long CTO.