Endovascular Treatment of Multilevel Chronic Total Occlusion Using a Stent Puncture Technique in Buerger's Disease

Abstract

We reported a patient with Buerger's disease who presented with critical limb ischemiawith prior recurrent occlusions after multiple surgical and endovascular treatments. Total occlusion of the whole native femoropopliteal and infrapopliteal arteries was observed. The femoropopliteal bypass graft, as well as a stent that was implanted in the mid-popliteal artery, were also occluded. Because of the lack of distal targets for bypass, surgical revascularization was not feasible; therefore, we decided to perform endovascular treatment. To overcome the limitation of vascular access, the previously implanted popliteal stent was directly punctured, and a guide wire was passed through the bypass graft. After the organized thrombus in the bypass graft was aspirated, further recanalization below the popliteal stent down to the plantar arteries was performed successfully. In conclusion, the stent puncture technique is a feasible and safe option for overcoming the limitations of vascular access in patients with multilevel occlusions.

Keywords: Endovascular procedures; Peripheral artery disease; Punctures; Stents; Thromboangiitis obliterans.

Fig. 1

Angiography of the patient's right lower extremity at the time Buerger's disease was first diagnosed. (A) Proximal part of superficial femoral artery was grossly normal without evidence of atherosclerosis while distal part of superficial femoral artery and popliteal artery were totally occluded with collateral vessels. (B) Below-the knee level angiogram showed total occlusion of popliteal artery, anterior tibial artery, and posterior tibial artery with collateral vessels. (C) Foot level angiogram showed the typical angiographic findings of corkscrew collateral vessel. (D) Final angiogram after endovascular treatment shows that that there was no residual stenosis in femoropopliteal artery.

Fig. 2

The patient's lower extremities, as observed via computed tomography angiography. (A) A maximum intensity projection reconstruction image shows total occlusion of the entire native femoropopliteal artery, the bypass graft, and below-the-knee arteries. (B) Axial images; white arrows indicate total occlusion of the surgical bypass graft and the stent that was implanted in the popliteal artery.

Fig. 3

Baseline angiography before endovascular treatment showed no visualized distal vessel to access. (A) Total occlusion of the previous femoral popliteal graft. (B) Below-the knee level angiogram showed total occlusion of the popliteal stent, anterior tibial artery, and posterior tibial artery. (C) Foot level angiogram showed total occlusion of the popliteal stent, anterior tibial artery, and posterior tibial artery.

Fig. 4

Step-by-step procedure scheme. (A) Direct retrograde puncture of the previous popliteal stent and advance of the 0.035-inch guide wire. (B) Thrombosuction with the 6-Fr shuttle sheath and an image of the retrieved material. (C) Wire-loop technique with a balloon support. (D) Balloon angioplasty of the posterior tibial artery and dorsal-plantar loop arteries. (E) Stenting at the proximal anastomosis site of the previous femoral popliteal bypass graft.

Fig. 5

Final angiogram. (A) Previous femoral popliteal bypass graft. (B) Image of stent in the popliteal artery. (C) Posterior tibial artery. (D) Dorsal-plantar loop arteries.