IVUS-Guided Wiring Improves the Clinical Outcomes of Angioplasty for Long Femoropopliteal CTO Compared with the Conventional Intraluminal Approach

Introduction of novel intravascular ultrasound preceding with angled guiding catheter (I-PAD) technique to treat chronic total occlusions in peripheral artery disease

BACKGROUND

The optimal endovascular treatment (EVT) for chronic total occlusion (CTO) lesions in patients with peripheral artery disease (PAD) has remained unestablished. We encountered a patient with PAD in whom CTO was successfully treated using a novel technique that involved intravascular ultrasound (IVUS) and angled guiding catheter: IVUS Preceding with Angled guiDing catheter (I-PAD) technique.

CASE PRESENTATION

A 74-year-old male presented with intermittent claudication attributed to CTO of the right external iliac artery. EVT was performed via the right common femoral artery. We retrogradely advanced the I-PAD system (i.e. partially extending the IVUS transducer portion from the tip of the angled guiding catheter) in the CTO lesion under the real-time guidance of IVUS imaging. We successfully traversed the CTO lesion without the use of a guidewire in approximately three minutes. The procedure concluded successfully without any procedure-related complications, following optimal stenting.

CONCLUSIONS

The I-PAD might be an effective technique to accurately, quickly, and safely pass through CTO lesions.

The mid-term effect of intravascular ultrasound on endovascular interventions for lower extremity peripheral arterial disease: A systematic review and meta-analysis

OBJECTIVE

Intravascular ultrasound (IVUS) is an important adjunctive tool for patients with lower extremity peripheral arterial disease (PAD) undergoing endovascular therapy (EVT). The evidence regarding the advantages of IVUS use is evolving, and recent studies have reported conflicting results. We aimed to perform a meta-analysis to evaluate the efficacy of IVUS during angiography-guided EVT for patients with PAD.

METHODS

MEDLINE and EMBASE were searched through April 2023 to identify studies that investigated the outcomes of IVUS with angiography-guided EVT vs angiography-alone-guided EVT. The primary outcome was restenosis/occlusion rate; secondary outcomes were target lesion revascularization, major amputation, and mortality.

RESULTS

One randomized controlled trial and 14 observational studies, largely of moderate quality, were included, yielding a total of 708,808 patients with 709,189 lesions that were treated with IVUS-guided EVT (n = 101,405) vs angiography-alone (n = 607,784). Compared with angiography alone, IVUS-guided EVT was associated with a non-significant trend towards decreased restenosis/occlusion (relative risk [RR], 0.74; 95% confidence interval [CI], 0.54-1.00; I2 = 60%). Although the risk of target lesion revascularization and mortality were comparable (RR, 0.85; 95% CI, 0.65-1.10; I2 = 70%; RR, 1.01; 95% CI, 0.79-1.28; I2 = 43%, respectively), the use of IVUS was also associated with significantly lower risk of major amputation (RR, 0.74; 95% CI, 0.67-0.82; I2 = 47%). Subgroup analysis focusing on femoropopliteal disease demonstrated significantly higher patency (RR, 0.72; 95% CI, 0.52-0.98; I2 = 73%). However, superiority with major amputation was not observed.

CONCLUSIONS

IVUS-guided EVT for PAD may possibly be associated with a lower major amputation rate compared with angiography alone-guided EVT, although the difference in patency remained an insignificant trend in favor of IVUS-guided EVT. Adjunctive use of IVUS during EVT may be beneficial, and further prospective studies are warranted to delineate this relationship and the applicability of this technology in routine practice.

Comparison of Aortobifemoral Bypass and Endovascular Treatment for Chronic Infrarenal Abdominal Aortic Occlusion From the CHAOS (CHronic Abdominal Aortic Occlusion, ASian Multicenter) Registry

PURPOSE

To directly compare the clinical outcomes of aortobifemoral bypass surgery (ABF) and endovascular treatment (EVT) for chronic total occlusion (CTO) of the infrarenal abdominal aorta (IAA).

MATERIALS AND METHODS

In this retrospective, multicenter study, we used an international database of 436 patients who underwent revascularization for CTO of the IAA between 2007 and 2017 at 30 Asian cardiovascular centers. After excluding 52 patients who underwent axillobifemoral bypass surgery, 384 patients (139 ABFs and 245 EVTs) were included in the analysis. Propensity score-matched analysis was performed to compare clinical results in the periprocedural period and the long-term.

RESULTS

Propensity score matching extracted 88 pairs. Procedure time (ABF; 288 [240-345] minutes vs EVT; 159 [100-205] minutes, p<0.001) and length of hospital stay (17 [12-23] days vs 5 [4-13] days, p<0.001) were significantly shorter in the EVT group than in the ABF group, while the proportions of procedural success (98.9% versus 96.6%, p=0.620), complications (9.1% versus 12.3%, p=0.550), and mortality (2.3% versus 3.8%, p=1.000) were not different between the groups. At 1 months, ABI significantly increased more in the ABF group for both in a limb with the lower (0.56 versus 0.50, p=0.018) and the higher (0.49 versus 0.34, p=0.001) baseline ABI, while the change of the Rutherford category was not significantly different between the groups (p=0.590). At 5 years, compared with the EVT group, the ABF group had significantly better primary patency (89.4±4.3% versus 74.8±4.3%, p=0.035) and survival rates (86.9±4.5% versus 66.2±7.5%, p=0.007). However, there was no significant difference between the groups for secondary patency (100.0%±0.0% versus 93.5%±3.9%, p=0.160) and freedom from target lesion revascularization (TLR) (89.3±4.3% vs 77.3±7.3%, p=0.096).

CONCLUSION

Even with recent advancements in EVT, primary patency was still significantly better for ABF in CTO of the IAA. However, there was no difference between the groups in terms of secondary patency and freedom from TLR at 5 years. Furthermore, there was no difference in procedural success, complications, mortality, and improvement in the Rutherford classification during the periprocedural period, with significantly shorter procedure time and hospital stay in the EVT group.

Delayed rupture of peroneal artery pseudoaneurysm following endovascular treatment in a patient with chronic limb-threatening ischemia: A case report

Below-the-knee (BTK) pseudoaneurysms that occur after endovascular therapy (EVT) and result in delayed rupture have rarely been reported. In this report, we present a rare case of an 86-year-old man with chronic limb-threatening ischemia who developed delayed rupture of an idiopathic pseudoaneurysm of the peroneal artery (PA) following EVT. The PA chronic total occlusion (CTO) was successfully crossed using a guidewire via an antegrade approach, however, subintimal crossing was confirmed by intravascular ultrasound. Balloon angioplasty was then performed using an appropriately sized balloon, resulting in successful recanalization of the PA CTO with minor dissection and no complications. Postoperatively, the patient's condition was stable until he suddenly complained of right calf pain 10 days after EVT. Computed tomography revealed a rupture of the PA pseudoaneurysm. Urgent angiography revealed two pseudoaneurysms, one saccular and the other spindle-shaped. The ruptured saccular aneurysm was successfully excluded through coil embolization and stent graft placement. To the best of our knowledge, this is the first reported case of delayed rupture of a BTK pseudoaneurysm following EVT. Balloon angioplasty in the subintimal space can lead to the formation of a pseudoaneurysm and its delayed rupture.

Clinical feasibility of endovascular recanalization with intravascular ultrasound-guided wiring for chronic total occlusion of below-the-knee arteries

BACKGROUND

Revascularization with endovascular therapy (EVT) for complex below-the-knee (BTK) chronic total occlusion (CTO) remains a challenging problem. The Japanese-BTK (J-BTK) CTO score is reported as an indicator of the difficulty of BTK CTO, with the guidewire (GW) passage success rate decreasing as the grade increases. We previously reported an effective GW crossing method for the intravascular ultrasound (IVUS)-guided parallel wiring of complex BTK CTO. In this study, we investigated the feasibility of EVT using IVUS-guided wiring for BTK CTO.

MATERIALS AND METHODS

This single center, retrospective study analyzed 65 consecutive BTK CTO vessels in which IVUS-guided wiring was attempted after the failure of a conventional antegrade wiring approach from November 2020 to November 2022. The primary endpoint was the clinical success of the target CTO vessel. The secondary endpoints were the GW success rate per grade based on the J-BTK CTO score, number of GW used for CTO crossing, fluoroscopy time, and complications.

RESULTS

Target vessels were the anterior tibial artery (66.2% of cases), peroneal artery (9.2%), and posterior tibial artery (24.6%). Blunt type CTO entry was performed in 55.4% of cases, calcification of entry was observed in 24.6% of cases, the mean occlusion length was 228.2 ± 93.7 mm, mean reference vessel diameter was 2.1 ± 0.71 mm, and outflow was absent in 38.5% of cases. J-BTK CTO scores of 0/1 (grade A), 2/3 (grade B), 4/5 (grade C), and 6 (grade D) were seen in 18.5%, 43.1%, 36.3%, and 1.5% of cases, respectively. The clinical success rate was 95.4%. The GW success rate by J-BTK CTO grade was as follows: grade A (100%), B (100%), C (91.7%), and D (0%). The mean number of GW used was 3.4 ± 1.4, the mean fluoroscopy time was 72.3 ± 32.5 min, and complications occurred in 7.7% of cases.

CONCLUSION

This study showed a very high clinical success rate despite the difficulty of BTK CTO. IVUS-guided EVT might be a feasible strategy for complex BTK CTO.

Intravascular Ultrasound-Guided Versus Angiography-Guided Endovascular Therapy for Femoropopliteal Artery Disease: A Scoping Review

OBJECTIVE

The objective of this study was to summarize whether the application of additional intravascular ultrasound (IVUS) can change the outcomes of endovascular treatment in femoropopliteal atherosclerotic lesions compared with conventional angiography alone based on the existing study and evidence.

METHODS

Studies published until September 2022 were searched from PubMed, Embase, and Cochrane databases using the methods of combination of Medical Subject Headings and free text words. The outcomes included in these studies were primary patency rate or restenosis rate and freedom from clinically driven target lesion revascularization (cdTLR) rate, and most studies were concerned about the 12-month results. Two independent authors conducted the process of study selection. And the pooled analysis was attempted.

RESULTS

Finally, the inclusion criteria were met by 4 studies (1 randomized controlled trial and 3 retrospective studies) involving 1160 patients. IVUS played its role in measuring lesions and/or guiding wiring passage. Most of the included studies showed that IVUS could achieve a higher 12-month primary patency rate (from 70% to 90%) and higher 12-month freedom from cdTLR rate (from 83.9% to 94.7%) than angiography. The tentative pooled analysis also showed that IVUS significantly improved the 12-month primary patency rate (OR: 2.21, 95%CI: [1.38-3.55], p=0.001) and the 12-month freedom from cdTLR rate (OR: 1.70, 95%CI [1.04-2.78], p=0.03) compared with angiography alone.

CONCLUSIONS

Intravascular ultrasound-guided endovascular treatment of femoropopliteal artery lesions may have its own advantages such as higher primary patency rate and freedom from cdTLR rate at 12 months. As a novel technology, IVUS is expected to become another beneficial option to guide clinicians performing endovascular therapy in addition to angiography and may achieve better clinical outcomes. More prospective and high-quality studies are needed in the future to investigate the role of IVUS in the process of femoropopliteal artery lesions endovascular treatment.

CLINICAL IMPACT

This review summarized a few available studies to promote understanding of IVUS and reveal its potential. This novel technology shows the possibility of achieving better clinical outcomes than angiography in femoropopliteal artery lesions endovascular therapy such as higher 12-month primary patency rate shown in some studies. Currently, it is important to consider suitable technologies applied to individualized treatment. IVUS seems to provide clinicians additional option in clinical practice and benefit patients well in the future. And it needs us to conduct more high-quality studies to explore its roles and advantages in endovascular treatment.

Comparison of angiography and ultrasound for femoropopliteal angioplasty: decision-making and 12-month outcomes

BACKGROUND

This study aimed to investigate whether intravascular ultrasound (IVUS) combined with angiography during percutaneous transluminal angioplasty impacts treatment strategies and the 12-month patency of the femoropopliteal artery, compared to angiography alone.

METHODS

This retrospective, single-center study enrolled 137 patients who underwent a femoropopliteal endovascular intervention between February 2020 and May 2021. Among these interventions, 43 were guided by IVUS combined with angiography and the remaining 94 were guided by angiography only. Treatment strategies and 12-month patency were analyzed in both groups. Multivariable analysis was performed to clarify the predictors of restenosis within 12 months.

RESULTS

Primary patency at 12 months was significantly higher in the IVUS group than in the angiography group (56.4% vs. 76.7%, P=0.047). The reference diameter on IVUS images was greater than that on angiography images. Therefore, the IVUS group presented a higher balloon-to-vessel ratio [1.0 (0.97, 1.01) vs. 1.06 (1.0.1.25)]. More adjunctive stents were required in the angiography group. However, more dissections were performed in the IVUS group, with no difference in flow-limiting dissections between groups. Target disease length (odds ratio 1.02, P=0.021) and balloon-to-vessel ratio (odds ratio 0.01, P=0.021) were independent predictors of restenosis.

CONCLUSIONS

Compared with angiography guidance alone, IVUS guidance for femoropopliteal artery-related treatment can significantly increase primary patency. This finding may be explained by the selection of larger balloons in IVUS and the resulting sufficient plaque compression and elastic membrane stretch. Moreover, IVUS was shown to detect more non-flow-limiting dissections than angiography.

A novel initial wiring technique for chronic total occlusion of the superficial femoral artery using the structural features of a polymer jacket guidewire

Background

To evaluate the efficacy of the GLadIus MG drilLINg technique (GLIMGLIN), a novel initial wiring technique using the Gladius MG™ structural features, for crossing the superficial femoral artery (SFA) with chronic total occlusion (CTO).

Methods

This retrospective, single-center study enrolled 27 symptomatic patients (mean age 77.4 ± 8.5 years; 20 men) with de novo SFA CTO (mean CTO length 16.1 ± 8.9 cm) who underwent GLIMGLIN as the initial wiring between January 2020 and December 2021. The success of GLIMGLIN was defined when the wire crossing was completed using a Gladius MG™ and a microcatheter without any additional devices and techniques.

Results

The success rate of GLIMGLIN was 48.1%. Intravascular ultrasound findings showed complete true lumen passage in the GLIMGLIN success group. Compared to the failure group, the proximal (6.3 ± 0.8 vs. 5.5 ± 0.9 mm, p = 0.02) and distal (5.9 ± 0.5 vs. 5.4 ± 0.6 mm, p = 0.02) reference vessel diameters were significantly larger, and the rate of calcium angle > 180° was significantly lower (30.8 vs. 71.4%, p = 0.04) in the success group. No significant difference was shown in the CTO length between two groups. Total wiring time, total procedure time, and fluoroscopic time were significantly shorter in the success group.

Conclusions

GLIMGLIN may enable operators to perform CTO wiring easily and efficiently in selected cases.

What should we expect from intravascular ultrasound use for complex femoropopliteal lesions?

In this review article, we summarize the clinical benefit of intravascular ultrasounds (IVUS) in the endovascular therapy (EVT) of complex femoropopliteal (FP) lesions. Due to the development of novel FP-dedicated devices, outcomes of FP-EVT have been improved. As a result, revascularization methods for the FP lesions have shifted to EVT. However, the long-term durability in complex FP lesions has not yet reached that of bypass surgery using autogenous vein. Strategies for EVT of complex FP lesions are still inconsistent and have room for improvement. Long-term results generally depend on the patient and lesion backgrounds but are also affected by the quality of the procedure. Previous reports have shown IVUS evaluation can better assess vessel size compared to conventional angiographic evaluation. In contrast to angio-guided EVT, which evaluates vessel size by inner diameter, IVUS can be evaluated it with an external elastic membrane, which leads to the selection of a more appropriate (basically, larger) size device. Conversely, angiographic evaluation underestimates the vessel size, suggesting that it may lead to insufficient result. Furthermore, IVUS can also assess the adequate guidewire route, presence of severe dissection etc. As the evidence so far shows, the use of IVUS may improve the quality of EVT procedure, resulting in improved long-term outcomes. In conclusion, despite the widespread use of IVUS in FP-EVT practice, it still conditionally applied. The purpose of IVUS in the EVT of complex FP lesions should be clarified. More evidence regarding the IVUS in complex FP lesions is needed.

Clinical Impact of Intravascular Ultrasound-Guided Fluoropolymer-Based Drug-Eluting Stent Implantation for Femoropopliteal Lesions

BACKGROUND

Treatment with a fluoropolymer-based drug-eluting stent (FP-DES has been widely applied to the contemporary femoropopliteal practice with durable outcomes. Nevertheless, the impact of intravascular ultrasound (IVUS) utilization on clinical outcomes after FP-DES implantation has not been determined.

OBJECTIVES

This study aimed to investigate the impact of IVUS on 1-year clinical outcomes after FP-DES) implantation for femoropopliteal lesions in patients with symptomatic peripheral artery disease.

METHODS

As a subanalysis of the CAPSICUM (contemporary outcomes after paclitaxel-eluting peripheral stent implantation for symptomatic lower limb ischemia with superficial femoral or proximal popliteal lesion) study, the present investigation analyzed 1,091 patients with symptomatic peripheral artery disease who underwent endovascular therapy with FP-DES for femoropopliteal lesions. One-year clinical outcomes were compared between patients treated with IVUS and those treated without IVUS after propensity score matching. The primary outcome measure was 1-year restenosis. The incidence of aneurysmal degeneration was also assessed.

RESULTS

A total of 843 (77.2%) patients underwent IVUS-guided FP-DES implantation. After propensity score matching, the 1-year restenosis was not significantly different between the groups (11.5% [95% CI: 9.1%-14.0%] vs 15.5% [95% CI: 10.9%-20.1%]; P = 0.22). The frequency of aneurysmal degeneration at 1 year was significantly higher in the IVUS group than in the non-IVUS group (19.8% [95% CI: 16.3%-23.4%] vs 7.1% [95% CI: 3.3%-11.0%]; P < 0.001). IVUS use was associated with a lower restenosis risk in patients with chronic total occlusion but not in those without (P for interaction = 0.044).

CONCLUSIONS

The present study revealed that 1-year restenosis risk was not significantly different between the 2 groups, whereas the incidence of aneurysmal degeneration was significantly higher in the IVUS group.

Angioscopic Findings of Stenosis Versus Occlusion in Femoropopliteal Artery Disease

BACKGROUND

Despite the increase in the number of patients with peripheral artery disease (PAD), the pathophysiology is not fully elucidated. Recently, angioscopy with a 0.48-megapixel equivalent resolution camera became available for patients with PAD. We aimed to compare the plaque component between native stenosis and occlusion in the femoropopliteal artery using this modality.

MATERIALS AND METHODS

Thirty-two consecutive patients who underwent endovascular treatment for native femoropopliteal artery disease with angioscopy were studied. The major angioscopic classifications of each lesion were defined as follows: atheromatous plaque (AP) was defined as luminal narrowing without any protrusion, calcified nodule (CN) was defined as a protruding bump with surface irregularity, a mainly reddish thrombus was defined as organizing thrombus (OG), and organized thrombus (OD) was defined by more than half of the thrombus showing a whitish intima-like appearance.

RESULTS

A total of 34 lesions (stenosis, n=18; occlusion, n=16) from 32 patients were included. All stenotic lesions showed AP or CN (n=8 [44%], n=10 [56%], respectively), whereas all occluded lesions showed OG or OD (n=5 [31%], n=11 [69%], respectively), which amounted to a statistically significant difference (p<0.001). In occluded lesions, stiff wires (>3 g) were required to cross all lesions classified as OD, whereas this was not always necessary for lesions classified as OG (11 [100%] of 11, 1 [25%] of 5, respectively; p=0.04). Yellow color plaques were observed to a similar degree in all angioscopic classifications. Major adverse limb events, defined as amputation and any reintervention at 12 months, were highly variable, depending on the angioscopic findings, and tended to be more frequently observed in CN and OD (13% in AP, 40% in CN, 0% in OT, and 36% in OD, p=0.25).

CONCLUSION

Angioscopy revealed varying components in stenosis and occlusion with different degrees of clinical impact. This may provide new information on the pathophysiology of PAD.

Predictability and usefulness of intravascular ultrasound-guided angioplasty in patients with femoropopliteal lesions: a systematic review and meta-analysis

INTRODUCTION

To assess whether intravascular ultrasound (IVUS)-guided angioplasty in femoropopliteal lesions would improve clinical outcomes and predict restenosis.

EVIDENCE ACQUISITION

Studies in which IVUS-guided angioplasty was used for femoropopliteal lesions were searched from the MEDLINE, Embase, Web of Science, and Cochrane databases; articles with the full text were included. The primary endpoint of this study was primary patency at 12 months, while the secondary endpoints were primary patency at 24 months, freedom from target lesion revascularization (TLR) at 12 months, and correlation of restenosis with the distal external elastic membrane (EEM) area, post-intervention minimum lumen area, lesion length, dissection, and calcification.

EVIDENCE SYNTHESIS

Altogether, 11 observational studies involving 1521 patients (1703 lesions) were analyzed. The quality of the evidence for 7 main outcomes was assessed as "very low" by The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) classification. The mean follow-up period was 1.5 years. The pooled rates were: 78% for 12-month primary patency (95% confidence interval [CI], 0.72-0.83), 74.3% for 24-month primary patency (95% CI, 0.71-0.78), and 80% for 12-month freedom from TLR (95% CI, 0.74-0.86). The 12-month primary patency of IVUS use (relative risk [RR], 2.01; 95% CI, 1.48-2.74) was higher compared to non-IVUS use. The minimum lumen (stent) area (standard mean difference (SMD) = -0.30; 95% CI, -0.46 to -0.15) and dissection (OR 1.58; 95% CI, 1.01-2.49, P = 0.047), were associated with midterm patency in terms of restenosis.

CONCLUSIONS

In IVUS-guided angioplasty in patients with femoropopliteal lesions, the minimum lumen (stent) area and dissection were associated with restenosis. Nevertheless, there is limited and heterogeneous evidence regarding the usefulness and Predictability of IVUS in patients with peripheral arterial disease in the femoropopliteal artery, especially in long-term patency and as a predictor of declining patency. The optimal role of IVUS in such patients should be elucidated in the future.

Validation of the correlation between angiosome-based target arterial path, mid-term limb-based patency, and the global limb anatomical staging system

This study aimed to validate the correlation between the Global Limb Anatomical Staging System (GLASS) and limb-based patency (LBP) and angiosome-based target arterial path (TAP) and to detect the predictors of LBP loss. After the publication of the Global Vascular Guidelines in 2019, the evaluation of GLASS and identification of TAP have been recommended. However, there are few reports regarding GLASS. Eighty-three patients with chronic limb-threatening ischemia (CLTI) and tissue loss from 2016 to 2020 were evaluated. The correlation between GLASS and LBP and successful revascularization of angiosome-based TAP was analyzed. We also investigated the predictors of LBP loss. The number of patients in each GLASS stage was as follows: GLASS I, 6 patients; GLASS II, 15 patients; GLASS III, 62 patients. At 6 months, the Kaplan-Meier estimate of LBP was 66.7% in GLASS I, 41.6% in GLASS II, and 16.4% in GLASS III, respectively (p = 0.034). The rate of successful revascularization of angiosome-based TAP was 100% in GLASS I, 86.7% in GLASS II, and 46.8% in GLASS III, respectively (p = 0.002). Multivariate analysis showed that the Wound, Ischemia, and foot Infection (WIfI) stage [hazard ratio (HR) 1.58; 95% confidence interval (CI) 1.07-2.33; p = 0.021] and GLASS infrapopliteal (IP) grade (HR 1.96; 95% CI 1.31-2.95; p = 0.001) were the independent predictors of LBP loss. The GLASS stage was significantly correlated with successful revascularization of angiosome-based TAP and mid-term LBP. The WIfI stage and GLASS IP grade were the independent predictors of loss of LBP.

Parallel Wiring Using a Single Intravascular Ultrasound Catheter with Double Rapid Exchange Lumens Technique for Chronic Total Occlusions in Peripheral Artery Disease

PURPOSE

To describe a parallel wiring using a single intravascular ultrasound catheter with double rapid exchange lumens (PASSABLE) technique for peripheral CTOs.

TECHNIQUE

The technique is demonstrated in a 73-year-old patient with CTOs of the superficial femoral and popliteal artery. Intravascular ultrasound (IVUS) examination revealed the first guidewire was advanced to the intramedial space of the popliteal artery. Following insertion of the first guidewire into only the distal rapid exchange lumen of the IVUS catheter and a second guidewire into the proximal rapid exchange lumen, a guidewire torquer was passed over it and tightened close to an exit port of the proximal rapid exchange lumen to prevent it from exiting an entry port while advancing the IVUS catheter. The IVUS catheter was advanced to the intraplaque region using only the distal rapid exchange lumen and the second guidewire was then advanced to the intraplaque region under IVUS guidance. The IVUS-guided wiring using the second guidewire on both the distal and proximal rapid exchange lumen was continued and resulted in a successful guidewire crossing into the distal true lumen.

CONCLUSION

This novel technique may prove beneficial in enabling operators to perform IVUS-guided parallel wiring more easily and efficiently.

Clinical outcome of drug-coated balloon versus scaffold device in patients with superficial femoral artery chronic total occlusion

The demand for endovascular therapy is increasing in an aging society, but the problem of restenosis in the chronic phase has not been resolved in femoropopliteal occlusive disease. Few studies have compared drug-coated balloon (DCB) and scaffold devices in chronic total occlusion (CTO) of the superficial femoral artery (SFA). This study aimed to compare DCBs with scaffold in patients with CTO of the SFA. This was a single-center, retrospective study. From June 2018 to December 2019, we compared 31 patients and 33 limbs treated with DCBs and 44 patients and 45 limbs treated with a stent or stent-graft (scaffold) for SFA CTO. The primary endpoint was 12-month primary patency. The secondary endpoints were 12-month freedom from clinically driven target lesion revascularization (CD-TLR) and 12-month freedom from re-occlusion. The DCBs were performed using an intravascular ultrasound (IVUS)-guided approach or a non-loop wire technique. Baseline characteristics were similar between the groups. An intraluminal approach was performed to use all DCBs. The bailout stent rate was 0% in the DCB group. Kaplan-Meier analysis showed that rates of 12-month primary patency tended to be higher in the DCB than in the scaffold group (92.7 vs. 76.6%, p = 0.073) and that freedom from CD-TLR also did not differ significantly between the two groups (96.8 vs. 86.3%, p = 0.17). Kaplan-Meier analysis also showed that the 12-month freedom from re-occlusion rate was significantly less in the Scaffold than in the DCB group (96.8 vs. 79.3%, p = 0.045). Therefore, we concluded that in treatment for CTO of the SFA, a DCB with intraluminal angioplasty without bailout stenting was less re-occlusion compared with scaffold.

Efficacy of navigating through the intraplaque route using AnteOwl WR intravascular ultrasound in femoropopliteal chronic total occlusion

BACKGROUND

There is no consensus on the optimal guidewire passage route for femoropopliteal (FP) chronic total occlusion (CTO). If intraplaque wiring can be performed, a stent-less strategy using a drug-coated balloon can be realized even with FP CTO, and there is a high possibility that good expansion can be obtained even when stent deployment is performed. AnteOwl WR (AnteOwl) is a novel intravascular ultrasound (IVUS) device useful for navigating the second guidewire into the intraplaque route under IVUS observation from the subintimal space. Here, we describe representative cases of FP CTO in which CTO-specific IVUS was extremely useful.

CASE PRESENTATION

Case 1 involved a 79-year-old man with total occlusion of the left superficial femoral artery (SFA). We used a contralateral antegrade approach, but the guidewire was advanced into the subintimal space. We advanced AnteOwl into the CTO. By utilizing the asymmetric structure of the transducer and the IVUS wire, we were able to reflect the positional relationship among the IVUS transducer, IVUS wire, and target plaque onto the angiographic image. By aiming the wiring in that direction, we succeeded in traversing the center of the plaque and finally succeeded in obtaining good expansion using the drug-coated balloon. Case 2 involved a 76-year-old woman with total occlusion from the SFA to the popliteal artery. We used an ipsilateral antegrade approach. When AnteOwl was placed on the wire and advanced to the popliteal artery, the subintimal space in the middle of the SFA could be visualized. We employed an IVUS-guided parallel wiring technique and succeeded in passing through all intraplaque routes. Although the CTO was long, we could easily advance through the intraplaque route by reflecting the information obtained from AnteOwl in angiography.

CONCLUSIONS

AnteOwl is an effective IVUS for FP CTO and facilitates a complex IVUS-guided procedure.