Augmented reality navigation to assist retrograde peroneal access for the endovascular treatment of critical limb ischemia

Abstract

Retrograde access is an alternative approach to endovascular intervention for critical limb ischemia but may be challenging in patients with poor below-knee vessel runoff. Here, we introduce an innovative technique based on an augmented reality navigation system to gain successful retrograde access to the peroneal artery of an 84-year-old woman with critical limb ischemia. Our result showed that this innovative technique had the potential advantage of influencing target vessel access selection with lower contrast material volume and radiation exposure compared with the conventional approach. More in-depth study is required to investigate the safety and efficacy of augmented reality-assisted vascular interventions.

Keywords: Augmented reality; Critical limb ischemia; Endovascular; Retrograde access.

Fig 1

Revascularization of popliteal artery and tibioperoneal trunk in patient with critical limb ischemia (CLI). Total occlusion of the right popliteal artery (A) and tibioperoneal trunk (B; arrow) was confirmed by angiography. The runoff vessels showed the posterior tibial artery and peroneal artery, with stenosis in the distal posterior tibial artery (C). Retrograde access to the peroneal artery was obtained, and the total occlusion of the tibioperoneal trunk was revascularized by balloon catheter of 2.5 mm in diameter (D; arrowhead).

Fig 2

Schematic diagram of the working principle of the augmented reality (AR) navigation system. CT, Computed tomography; MR, magnetic resonance.

Fig 3

Retrograde access to the peroneal artery was guided by the augmented reality (AR) navigation system. The Digital Imaging and Communications in Medicine image data were input to the three-dimensional reconstruction processing system (A), which created the puncture path with incorporation of cross-sectional, sagittal, and coronal images. The optimal path to the target vessel was shown on the computer with the given depth and puncture angle (B). As shown in (C), the red dot is the target vessel, and the four yellow dots represent four tracking markers attached to the patient's leg, with one of them set as the putative puncture site. The puncture path was then displayed on the AR glasses, and the operator adjusted the needle and aligned it with the green dots and the blue route toward the target vessel (D). Note that the tracking markers on the leg overlapped the yellow dots displayed on the AR glasses.