Trans-dorsalis pedis artery approach for patients with chronic total occlusion of superficial femoral artery after Y-graft surgery

Abstract

A 75-year-old man was admitted to our department with coldness in the left lower limb and intermittent claudication. The claudication distance was 30 m with no resting pain and was classified as Fontaine stage II b and Rutherford I-2. His medical history included Y-graft bypass grafting from the aorta below the renal artery to the proximal femoral artery 11 years before abdominal aortic aneurysm. Magnetic resonance angiography and contrast-enhanced computed tomography revealed a chronic total occluded lesion in the left superficial femoral artery (SFA), but the distal flow was maintained at the dorsalis pedis artery (DPA). Endovascular therapy (EVT) was performed for a chronic total occlusion (CTO) TransAtlantic Inter-Society Consensus class II type B lesion from the distal SFA to the popliteal artery using the DPA approach as the artificial bypass prevented bilateral common femoral artery puncturing (Fig. 1a). Severe calcification up to the P2 segment of the popliteal artery prevented popliteal artery puncturing (Fig. 1c). A 0.035-inch wire was inserted through DPA with a vessel diameter of approximately 3 mm under echographic guidance; a Parent Plus 60-cm 6-Fr guide catheter (Medikit, Tokyo, Japan) was inserted through the left DPA to the distal SFA (Fig. 1a, arrow, 1d) using the retrograde approach. We succeeded in crossing the CTO lesion of the left SFA using the combination of an Astato 9–40 0.014-inch guidewire (Tokai Medical Products, Aichi, Japan) and a Corsair Armet 90-cm microcatheter (Asahi Intecc, Nagoya, Japan). The entire CTO lesion was dilated using a 6.0 × 150 mm SIDEN HP balloon (KANEKA Medics, Osaka, Japan) (Fig. 1e). Three overlapping ELUVIA paclitaxel-eluting vascular stents (7.0 × 120, 7.0 × 120, and 7.0 × 80 mm; Boston Scientific Marlborough, MA, USA) were successfully placed (Fig. 1f) with no complications. After the procedure, STEPTY (NICHIBAN Co, Tokyo, Japan) was applied at the site to stop the flow of blood through pressure immobilization. Under light pressure, the catheter was retrieved, followed by tight application of STEPTY and an elastic bandage for 4 h after EVT (Fig. 1g, h). The patient was almost symptom-free after treatment, and the ankle-brachial pressure index improved from 0.76 before treatment to 1.04 after treatment. The DPA approach is useful in patients for whom femoral and popliteal access approaches are unsuitable and the anterior or posterior tibial artery is not stenotic. This approach has several advantages over femoral, popliteal, brachial, and radial approaches for EVT. First, compared with the radial approach, the DPA approach has a shorter distance to SFA (70 vs. 140 cm, respectively) and a stronger backup, making it suitable for CTO and calcified lesions where the bilateral common femoral artery and popliteal access approaches are difficult. Second, compared with other approaches, the DPA approach can decrease access-site-related complications and increase patient comfort with early ambulation. Possible complications of the DPA approach include bleeding, hematoma, pseudoaneurysm, arteriovenous fistula, nerve damage, osteonecrosis, and access-site artery occlusion, but almost no complications have been reported [1, 2]. Therefore, single primary access through DPA is feasible and safe for balloon angioplasty and CTO stenting.