Aortoiliac Occlusive Disease Revascularization Utilizing Crossing With OCT Imaging, Re-entry With IVUS Imaging, and Stenting With CERAB Technique

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1 ortoiliac Occlusive Disease Revascularization Utilizing Crossing With OCT Imaging, Re-entry With IVUS Imaging, and Stenting With CERB Technique Judd Salamat, DO; Vincent Varghese, DO; Jon C. George, MD From the Department of Interventional Cardiology and Endovascular Medicine, Deborah Heart and Lung Center, Browns Mills, New Jersey. BSTRCT: 74-year-old female with history of coronary artery disease, peripheral arterial disease including carotid stenosis treated with carotid endarterectomy, and chronic obstructive pulmonary disease presented with complaints of shortness of breath and episodic neck and jaw discomfort. Her symptoms were of sudden onset while at rest, initially occurring several days prior to admission. The patient was treated by percutaneous coronary intervention (PCI) of the right coronary artery in the setting of non-st segment elevation myocardial infarction and aortoiliac occlusive disease (IOD). Failed initial attempt at PCI via right radial artery access required urgent endovascular revascularization of IOD in order to gain femoral artery access for PCI. The aortoiliac occlusion was crossed using the Ocelot system (vinger) with OCT imaging, and re-entry using the Pioneer system (Volcano Corporation) with IVUS imaging. VSCULR DISESE MNGEMENT 2015;12(1):E2-E9 Key words: percutaneous coronary intervention, occlusion, aortoiliac artery, chronic occlusion, endovascular therapy 74-year-old female with history of coronary artery disease (CD), peripheral arterial disease (PD) including carotid stenosis treated with carotid endarterectomy, and chronic obstructive pulmonary disease presented with complaints of shortness of breath and episodic neck and jaw discomfort. Her symptoms were of sudden onset while at rest, initially occurring several days prior to admission. Laboratory findings revealed mild respiratory acidosis, elevated D-dimer, mild renal insufficiency, and moderate hyperglycemia. Cardiac enzymes and complete blood counts were within normal limits. Initial electrocardiogram showed sinus tachycardia, left axis deviation, and nonspecific ST-segment and T-wave abnormalities in the inferior limb leads. Chest radiograph showed cardiomegaly with mild interstitial edema and upper-lobe emphysema. lung perfusion scan reported intermediate Vascular Disease Management January

2 B Figure 1. Selective angiograms of bilateral femoral arteries demonstrating chronic total occlusion (arrows) of right () and left (B) common iliac arteries. probability for pulmonary embolus. The patient was treated initially for exacerbation of chronic obstructive pulmonary disease by BiPP ventilation, nebulized bronchodilators, intravenous steroids, and broad-spectrum antibiotics and her symptoms improved. However, repeat cardiac enzymes revealed elevated biomarkers (creatine phosphokinase 245, troponin I 4.04) with recurrence of neck and jaw discomfort. Standard medical therapy for acute coronary syndrome was initiated, and the patient was referred for cardiac catheterization and coronary angiography. Urgent cardiac catheterization was performed via a right femoral arterial approach. The access wire could not be advanced beyond the right external iliac artery and selective angiogram revealed complete occlusion of the right common iliac artery (CI) (Figure 1). ccess was then obtained in the left common femoral artery (CF) with similar results confirming complete occlusion of the left CI (Figure 1B). Right radial arterial access was then obtained for coronary angiography. Left ventriculogram showed mild hypokinesis of the anterolateral wall and apex and severe hypokinesis of the inferior and posterobasal walls, with estimated ejection fraction of 40%. Mild disease was present in the left main and left anterior descending (LD) arteries. The left circumflex artery was 100% occluded at the ostium, with mid to distal vessel reconstitution via collaterals from the LD. The right coronary artery (RC) was dominant with 90% calcified stenosis in the proximal segment. Multiple guides were used to engage the RC via radial approach but with inadequate support to advance a balloon across the lesion, despite the use of a Guideliner (Vascular Solutions) as a guide extension and an Vascular Disease Management January

3 Emerge balloon (Boston Scientific) as an anchor balloon in the conus branch artery. fter prolonged attempts that ultimately failed, PCI of the RC via radial approach was aborted. Descending aortogram revealed an ulcerated eccentric lesion below the renal arteries with 100% distal occlusion (Figure 2). Extensive collaterals from the lumbar and mesenteric arteries were noted to reconstitute bilateral external iliac arteries. t this point, due to failed revascularization of the RC from radial approach, endovascular revascularization of the aortoiliac occlusion was planned to allow PCI with better guide support from the femoral approach. n interim computed tomography angiography of the descending aorta and lower extremity runoff confirmed the findings on the aortogram with no suggestion of a thrombosed abdominal aortic aneurysm. primary retrograde revascularization approach was selected as the primary strategy due to minimized risk of extravasation with perforation compared to an antegrade perforation. ccess was obtained in the left brachial artery for positioning of a pigtail catheter within the distal aorta to delineate the true lumen. This access was also available as an option for a retrograde intraaortic balloon pump placement if the patient became hemodynamically unstable in the setting of unrevascularized coronary artery disease. n Ocelot catheter (vinger) was advanced from the right CF to cross the chronic total occlusion (CTO) in the CI (Figure 3) with optical coherence tomography (OCT) imaging (Figure 3B) to allow direct visualization during crossing and to maintain intraluminal position. lthough the catheter maintained this position up to the aortoiliac bifurcation, it entered into a subintimal plane in the distal aorta due Figure 2. Distal aortogram confirming infrarenal aortic occlusion (arrow) with extensive collaterals. to heavy distal calcifications despite multiple attempts to maneuver the catheter within the lumen. Grand Slam guidewire (bbott Vascular) was maintained in this position in the subintimal plane from the right femoral access. The same steps were then performed from the left CF to wire the subintimal plane in the distal aorta and another Grand Slam guidewire maintained in this position from the left femoral access. Pioneer Plus re-entry catheter (Volcano Corporation) was then advanced over the Grand Slam wire from the right-sided access (Figure 4) to re-enter the true lumen of the aorta with intravascular ultrasound (IVUS) guidance (Figure 4B), allowing the re-entry wire to advance into the proximal descending aorta. The same technique was then repeated from the leftsided access to maintain a guidewire in the proximal descending aorta. Simultaneous balloon angioplasty was performed of the reentry site with two 6 x 40 mm Vascular Disease Management January

4 B Sterling balloons (Boston Scientific). single icst 10 mm x 38 mm balloon-expandable covered stent (Maquet) was deployed as a distal aortic cuff in the infrarenal position (Figure 5). Two icst 7 mm x 59 mm covered stents were then simultaneously deployed to extend from within the initial aortic cuff stent into the bilateral CIs (Figure 5B). Two additional icst 7 mm x 59 mm stents were then deployed in bilateral CIs to cover the entire occluded segment. Final aortogram from the left radial artery access site confirmed patent aortic stents with bilateral limb extensions with brisk flow (Figure 6). Both internal iliac arteries were noted to be patent. Hemostasis was achieved in bilateral femoral access sites via manual compression upon normalization of activated clotting time. The staged PCI of the proximal RC was successfully performed during the same hospitalization via right femoral arterial access with the use of a larger supportive guide, buddy wires, and Guideliner allowing deployment of a 2.75 mm x 14 mm Integrity bare-metal stent (Medtronic). There were no periprocedure or postprocedure complications and the patient s symptoms completely resolved with subsequent discharge to a rehabilitation facility. Figure 3. Ocelot catheter (arrow) advancement to cross iliac chronic total occlusion () utilizing OCT imaging (B) to direct the catheter away from healthy tissue (*) and toward atherosclerotic plaque (arrow). DISCUSSION It is well known that patients with PD also have concomitant CD, with 20% to 60% increased risk of myocardial infarction (MI). 1 The coexistence of IOD commonly referred to as Leriche syndrome, in the setting of acute MI represents an interesting therapeutic dilemma in PCI. 2 The advent of radial artery access for PCI has proven effective as a safer approach of treatment for obstructive CD owing to a decreased risk of bleed- Vascular Disease Management January

5 B Figure 4. Pioneer catheter (arrow) positioning in distal aorta () for re-entry utlizing IVUS imaging (B) to direct the needle from the subintimal plane (*) into the true lumen (arrow). ing; however, when radial artery access is not an option, other access points must be considered. Conventional TSC II treatment guidelines recommend Type C and D lesions be treated surgically. 3 However, considering that the patient population is aging, comorbidities are increasing, and there have been significant technical advancements in endovascular treatment, an endovascular approach to treating IOD may offer lower perioperative risk with comparable outcomes. 4 Leriche syndrome, or CTO of the infrarenal aorta and bilateral CIs, is classified as a TSC II Type D lesion. Conventional recommendations advise using an open surgical repair over endovascular treatments. 3 lthough 5-year patency rates after aortobifemoral bypass are higher than 5-year patency rates after endovascular treatment, recent data suggest early clinical success rates of 93% with primary stenting and comparable secondary patency rates. 5 dvancements in endovascular technology and technique as well as growing operator experience have allowed for greater success rates in IOD, making an initial endovascular approach a feasible and safe option. 6-9 Various techniques have been described for successful endovascular revascularization of IOD. In this case, we performed retrograde subintimal angioplasty of a chronically occluded distal abdominal aorta and bilateral iliac arteries utilizing the Ocelot system and Pioneer Plus re-entry catheter. Our initial approach with the Ocelot system, which uses OCT for visual guidance of the catheter tip to traverse the CTO, was successful in crossing the majority of the occlusion in the CI but was unable to enter the true lumen in the proximal cap of the distal aorta. The Ocelot device has been proven to be safe and effective in crossing CTOs Vascular Disease Management January

6 of the superficial femoral and popliteal arteries, with a reported success rate of 97% when used alone, with an assist device, or with a re-entry device. 10 The Pioneer Plus re-entry device has been shown to improve success rates of CTO subintimal angioplasty from 74% to 87% at minimum to 95% to 100% at maximum. 11 While the use of adjunctive devices increases the cost of performing the procedure, their use theoretically increases the technical success of the procedure by providing direct visualization and decreases potential complications. The Covered Endovascular Reconstruction of the ortic Bifurcation (CERB) technique, recently described by Goverde and Grimm et al, involves 3 PT- FE-covered balloon-expandable stents. ngioplasty of the distal aortic stenosis with a large-diameter stent is performed followed by kissing stents of bilateral CIs with placement of the proximal portions within the distal aortic stent In vitro models suggest that the CERB technique minimizes radial mismatch of the kissing stents within the distal aorta. 7,14 Furthermore, several studies indicate that covered stents outperform bare metal stents in angioplasty of TSC C and D lesions Long-term follow-up of successful IOD revascularization utilizing the CERB technique is needed to determine procedural durability. Meanwhile, the technologic advances, operator experience, safety, and feasibility of treating IOD by an endovascular approach have led to a recent consensus statement for utilizing an endovascular-first strategy in patients with TSC D IOD. 18 We report a case of PCI of RC in the setting of NSTEMI and IOD and failed initial attempt at PCI via right radial artery access requiring urgent endovascular revascularization of IOD for need of femoral Figure 5. Distal aortic covered stent (arrow) placement () followed by bilateral kissing (arrows) CI stents (B). B Vascular Disease Management January

7 Figure 6. ifinal aortogram confirming successful revascularization of the distal aortic occlusion into bilateral iliac arteries. artery access for PCI. The aortoiliac occlusion was crossed using the Ocelot system with OCT imaging, and re-entry was performed using the Pioneer Plus system with IVUS imaging. To our knowledge, there is no prior reported use of the Ocelot system in crossing aortoiliac CTOs. The CERB technique was employed to reconstruct the infrarenal aorta and bilateral iliac arteries, which allowed for successful PCI of the RC by femoral artery access. Editor s note: Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. George reports consultancy to Covidien and Gore. The remaining authors report no disclosures related to the content herein. Manuscript submitted ugust 13, 2014; final version accepted October 10, ddress for correspondence: Jon C. George, MD, Director of Clinical Research, Division of Cardiovascular Medicine, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ, 08015, US. jcgeorgemd@gmail.com. REFERENCES 1. Hirsch T, Haskal ZJ, Hertzer NR, et al. CC/H 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the merican ssociation for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular ngiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the CC/H Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral rterial Disease) endorsed by the merican ssociation of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; Transtlantic Inter-Society Consensus; and Vascular Disease Foundation. J m Coll Cardiol. 2006;47(6): Niizeki T, Kaneko K, Sugawara S, et al. Successful revascularization to right coronary artery by percutaneous coronary intervention after endovascular therapy for Leriche syndrome. Clin Med Insights Case Rep. 2014;7: Norgren L, Hiatt WR, Dormandy J, et al. Inter- Society Consensus for the management of peripheral arterial disease (TSC II). J Vasc Surg. 2007;45(suppl S):S5-S Soga Y, Iida O, Kawasaki D, et al. Contemporary outcomes after endovascular treatment for aorto-iliac artery disease. Circ J. 2012;76(11): Ye W, Liu CW, Ricco JB, Mani K, Zeng R, Jiang J. Early and late outcomes of percutaneous treatment of Transtlantic Inter-Society Consensus class C and D aorto-iliac lesions. J Vasc Surg. 2011;53(6): Setacci C, Galzerano G, Setacci F, et al. Endovascular approach to Leriche syndrome. J Cardiovasc Surg (Torino). 2012;53(3): Sharafuddin MJ, Hoballah JJ, Kresowik TF, Sharp WJ. Kissing stent reconstruction of the aortoiliac bifurcation. Perspect Vasc Surg Endovasc Ther. 2008;20(1): Vascular Disease Management January

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