Technique for Endovascular Needle Assisted Sharp Recanalization of Aortoiliac Occlusive Disease in a Nonsurgical Patient

Purpose:
To describe a technique for sharp endovascular aortoiliac recanalization in nonsurgical patients who have failed traditional wire and catheter techniques.

Material and Methods:
A 50-year-old male presented with rest leg pain and occluded right common iliac artery. Endovascular therapy was preferred over surgery due to comorbidities. Sonography confirmed patent bilateral common femoral arteries. Retrograde needle access was obtained Seldinger technique was used to place bilateral 7F sheaths. An 035 guidewire and angled catheter were negotiated through the left iliac artery into the abdominal aorta. Subsequent aortogram via pigtail catheter confirmed occlusion of the right common iliac artery. Retrograde canalization of the occlusion was attempted with several catheter and wire combinations, but only three-quarters could be crossed. Antegrade navigation through the occlusion via reverse curve catheter from contralateral access also failed. Occlusion morphology precluded use of a re-entry device. An angled catheter via right sided access was placed as cranially as possible in the occlusion and angiography with subtractive imaging overlay performed. A 65.5 cm x 21-gauge needle was advanced via the angled catheter, and under frontal and lateral fluoroscopic guidance, was used to puncture through the occlusion into the aorta. An 018 wire was advanced to secure access, the needle removed, the angled catheter advanced over wire, and contrast injected to confirm endoluminal position. Angiography with vessel measurement was performed and bilateral 6mm balloon expandable stents were placed in a kissing fashion at the aortic bifurcation. Additional bare metal stents were placed extending the reconstruction cranially and caudally. Completion angiography demonstrated good flow through all vessels.

Results:
Complete patency of the reconstructed right iliac artery was achieved. Patient had improvement in all symptoms and no evidence of complication at follow up to 6 months. A follow-up CT exam demonstrated sustained patency of the reconstruction.

Conclusions:
Needle assisted recanalization of an artery is feasible under fluoroscopic guidance. Intra-vascular ultrasound (IVUS) would be helpful post sharp recanalization to ensure endoluminal access is achieved before device deployment. Further investigation is required to fully establish a safety profile long term procedural viability.