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Abstract 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.

Abstract Background The transradial approach (TRA) is associated with fewer serious access site-related complications compared with the transfemoral or transbrachial approach. However, TRA has associated problems in complex aortoiliac (AI) lesions, including the procedural difficulty. A bidirectional approach was used combining TRA with a sheathless technique for femoral artery (FA) puncture to treat complex AI lesions, as a minimally-invasive approach. This report describes a representative cases with AI chronic total occlusion in which the combination of TRA and a sheathless technique for FA puncture was useful for guidewire crossing. Case presentation Case 1 was a 71-year-old man with intermittent claudication (IC). Control angiography showed total occlusion of the left common iliac artery (CIA) ostium to the distal external iliac artery (EIA). Guidewire externalization was achieved by combining TRA using a 6Fr guiding sheath and a sheathless technique for the left FA. Two nitinol stents were deployed in the CIA to EIA. Case 2 was a 63-year-old man with IC. Control angiography revealed total occlusion of the right CIA ostium to the common femoral artery (CFA) with severe calcification. The antegrade wire could not pass through the CTO lesion because of the calcified CFA occlusion. A 21-G metal needle was used to penetrate the CFA calcification through the distal true lumen of the CFA, and the wire was inserted into the EIA for wire externalization. Three nitinol stents were deployed in the CIA to EIA, and a drug-coated balloon was dilated in the CFA with hemostasis of the distal puncture site. In both cases, the retrograde puncture site was hemostatic during the procedure and postoperative bed rest was not required. Conclusions TRA combined with a sheathless technique from the FA has the potential to treat AI complex lesions in a less invasive manner.

Abstract Background Although endovascular therapy is used to treat chronic limb-threatening ischemia, long chronic total occlusion (CTO) is still challenging to treat. Especially in patients with poor run-off below-the-knee (BTK) arteries, it is difficult to perform a retrograde approach, and even guidewire passage may be difficult. Case presentation We treated two cases of chronic limb-threatening ischemia using our novel extreme antegrade guidewire crossing technique by AnteOwl WR intravascular ultrasound (IVUS)-guided parallel wiring to a BTK artery (EXCAVATOR technique). Case 1 was a 70-year-old man with ulceration of the right toe. The AnteOwl WR IVUS was intentionally advanced into the subintimal space of the posterior tibial artery, and the totally intraplaque route was advanced by IVUS-guided parallel wiring that was successfully passed from the lateral plantar aspect to the true lumen of the digital artery. Case 2 was a 76-year-old woman with rest pain and cyanosis of the right lower limb. Angiography showed total occlusion from the superficial femoral artery to BTK arteries. AnteOwl WR IVUS-guided parallel wiring was repeatedly performed until the distal true lumen of the peroneal artery was reached, and revascularization was successfully achieved via the antegrade approach alone. Conclusions With its excellent crossable performance, good image quality, and high navigational ability within the CTO, the AnteOwl WR can be used to pass parallel wiring into the distal true lumen for BTK CTO.

Abstract 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.

Abstract Background Surgical endarterectomy for common femoral artery (CFA) disease is still considered the gold standard for treatment. Development of various techniques and devices has improved the clinical results of endovascular therapy (EVT) for CFA. However, severe conditions remain, especially for occlusive lesions owing to calcified plaque. We developed a useful technique for passing a lesion by directly penetrating the calcified plaque of the CFA using a bare metal needle and then passing through a balloon or dilating it. We named this technique “direct bare metal needle puncture and balloon angioplasty in calcified plaques of the common femoral artery guided by angiography” or “BAMBOO SPEAR.” Main text This report describes our technique for crossing a lesion by directly penetrating the calcified plaque of the CFA using a needle. We report a case of a 73-year-old male with hemodialysis who presented with cyanosis and ischemic rest pain of both lower limbs. Control angiography showed total occlusion of the left CFA with a calcified plaque. We advanced a 21-G metal needle that was slightly curved into the blood vessel from where the lumen of the distal CFA was located. The needle was advanced into the center of the calcified plaque, while observing from multiple directions with a fluoroscopic guide. We succeeded in advancing the needle into the lumen of the distal external iliac artery. After guidewire crossing, intravascular ultrasound (IVUS) showed that guidewire was able to completely pass through the center of the calcified plaque. We could dilate the lesion by scoring balloon and drug-coated balloon. The final angiography showed sufficient results. We named this technique “direct BAre Metal needle puncture and BallOOn angioplaSty in calcified PlaquEs of the common femoral ARtery guided by angiography” (BAMBOO SPEAR). Conclusions The BAMBOO SPEAR technique may be considered a useful option in EVT for occlusive CFA with calcified plaques.

Abstract Background There are still cases that are difficult to treat for femoropopliteal chronic total occlusion (CTO). The Outback® Elite catheter is effective re-entry device to treat such kind of difficult cases, however, it might be difficult to use the Outback® Elite catheter antegradely in cases with severely calcified lesions. In this case, we performed EVT using the Outback Elite® catheter via the retrograde popliteal approach. Case presentation We report a case of a 77-year-old male with end-stage renal disease who presented with pain and cyanosis of his left foot. Control angiography showed total occlusion from the middle of the left superficial femoral artery to the proximal portion of the popliteal artery. The CTO lesion was severely calcified, which prevented the antegrade advancement of any guidewire. Retrograde popliteal puncture was performed with the patient in the supine position. After intentional retrograde subintimal wiring, the Outback® Elite catheter was advanced via the retrograde approach after the identification of a suitable re-entry site using intravascular ultrasound. After wire crossing, one nitinol stent was deployed and sufficient antegrade flow was achieved without any complications. Conclusions Using Outback® Elite from retrograde should be considered in cases where antegrade advancement fails and bidirectional wiring cannot pass through the CTO lesion.

Abstract Background The usefulness of endovascular therapy (EVT) for the iliac artery has been established. However, difficult cases such as a long total occlusion and tortuous vessels are sometimes encountered. We recently performed rotational angiography with an angiography machine immediately before EVT and fused three-dimensional (3D) anatomical information obtained from preoperative enhanced computed tomography (CT) that had been performed in advance to create a 3D roadmap. We termed this method the CT fusion 3D roadmap (CTf3D-RM) technique and used it for treatment of iliac occlusive disease. Case presentation A 73-year-old man presented with pain in his left leg while resting. CT showed total occlusion from the ostium of the common iliac artery (CIA) to the distal part of the external iliac artery (EIA). A guiding sheath was inserted from the left common femoral artery using the CTf3D-RM technique, and the occlusive vessel was clearly observed. The guidewire could be passed retrogradely without bidirectional wiring. The time taken to pass the guidewire was only about 9 min despite the long and hard chronic total occlusion (CTO). Intravascular ultrasound showed that all of the guidewire followed the intraplaque route. After ballooning the entire lesion, we deployed two stent grafts and three bare nitinol stents from the left CIA ostium to the distal EIA. Final angiography showed good expansion and sufficient flow to the left leg. Conclusions The use of a 3D roadmap by fusion of CT angiography with volumetric data from an angiography machine in EVT for iliac CTO was shown to be effective.