Three-Dimensional Angiography-Guided Percutaneous Transluminal Angioplasty for Distal Aorta and Bi-Iliac Chronic Total Occlusion
A 54-year-old man presented with severe claudication and coldness in both lower extremities several years ago. The ankle-brachial index of both lower extremities was not measurable. The lower extremity CT angiogram showed total occlusion from the infra-renal distal abdominal aorta to both external iliac arteries. There was a2013-05-06 well-developed inferior mesenteric artery (IMA) forming multiple collaterals at the distal abdominal aorta, but a definite angiographic stump of the distal aorta to the iliac arteries was not visible (). A CT angiogram was not enough to detect the stump of an occlusive lesion in the distal aorta and relationships to surrounding vessels. So we considered 3D full rotational angiography and spatio-temporal reconstruction for detecting the stump at the distal aorta and additional vascular structures.\nFirst, an aortography was performed via radial approach with a 5 Fr pigtail catheter. The aortography showed that there was total occlusion at the distal abdominal aorta below both renal arteries and total occlusion at the proximal bi-iliac arteries. Although there was a severe discrete concentric stenosis in the ostium (OS) of IMA, the entire vessel was well-developed which gave rise to profuse collaterals to the bi-iliac arteries from the distal to the occluded segment.\nVascular access was achieved via both femoral arteries and right brachial artery. 8 Fr short sheaths were inserted to both femoral arteries for a retrograde approach and an 8 Fr Vistabrite IG guiding sheath (Johnson & Johnson, Miami, FL, USA) was inserted to the right brachial artery for anterograde approach.\nA full rotational 3D angiography was performed and spatiotemporal reconstruction was carried out by Philips cine angiography FD 20 software (Philips, Amsterdam, the Netherlands). Mapping with 3D reconstructed images, an endoview showed a blunt stump in the distal aorta just distal to the IMA OS which was not shown on the CT or invasive diagnostic aortography ().\nThere was a suspicious micro-channel from the distal abdominal aorta to the right iliac artery from 3D rotational angiography (, transparent arrow). This micro-channel was not observed by previous CT angiography. A virtual line could be drawn from the suspicious stump in the distal abdominal aorta to the right iliac artery (, dot line). A successful guidewire passage was achieved through this micro-channel.\nUnder the 3D image guide, aggressive bilateral kissing wiring was performed using 035 soft long Terumo wire (0.035 Radiofocus® Guidewire M, Terumo Corp., Somerset, NJ, USA) under the 5 Fr multipurpose-1 catheter support from the distal aorta to the right iliac artery and from the right femoral artery to the right iliac artery by subintimal approach (). After successful 035 guidewire passage from the aorta to both iliac arteries, sequential predilation was done using Powerflex 6.0×80 mm (Johnson & Johnson, Miami, FL, USA) from the distal aorta to both external iliac arteries (). After the predilation of both entire iliac arteries to the distal aorta, simultaneous kissing stenting was performed using two Smart control stents {7.0×100 mm (aorta to right iliac artery)/6.0×100 mm (aorta to left iliac artery) ()}. Residual stenosis was approximately 40% and good distal flow was observed. To get optimal angiographic results, final kissing ballooning was carried out using two Powerflex 6.0×80 mm balloons. A final angiogram showed excellent angiographic outcomes (good distal run-off without flow limitation) (). The patient was stabilized and safely discharged for regular clinical follow up.