Recanalization of Total Occlusion of the Superficial Femoral Artery and Profunda Femoris Using the Transcollateral Approach

Abstract: Chronic total occlusions (CTOs) are seen in 30%-40% of symptomatic superficial femoral artery (SFA) disease. Despite advances in revascularization techniques, 10%-20% of these occlusions cannot be crossed. We report 1 case and review the literature on transcollateral retrograde crossing of the SFA from the profunda femoris. The procedural steps and devices (wires and crossing catheters) utilized by various operators are outlined. Based on an overview of current cases in the literature (19 cases, 21 CTOs), success rate was 95.2% with no complications reported. We conclude that transcollateral recanalization of chronically occluded SFA appears to be a viable technique when antegrade access is not feasible. 

J INVASIVE CARDIOL 2017;29(4):E43-E46

Key words: transcollateral, superficial femoral artery, total occlusion, profunda femoris, dissection, access-site complication, retrograde recanalization

Chronic total occlusion (CTO) of the superficial femoral artery (SFA) is frequently encountered during percutaneous infrainguinal revascularization.¹ Multiple approaches have been developed to cross CTOs including antegrade intraluminal crossing or a subintimal approach with or without the aid of crossing or reentry catheters, respectively.  Despite these attempts, approximately 20% of these occlusions cannot be crossed.^2,3 The retrograde transpopliteal approach has been most commonly used as an alternative method to recanalize CTOs of the SFA when antegrade methods have failed.⁴ Recently, distal SFA⁵ and pedal arteries⁶ have been introduced as access sites to accomplish retrograde crossing with the added advantage of keeping the patient in a supine position. However, the use of a retrograde technique after the failure of an antegrade approach requires another arterial puncture and may increase the risk of access-site complications. Herein, we present a sample case from our cardiac catheterization laboratory to illustrate this methodology and review the literature on transcollateral retrograde crossing of the SFA from the profunda femoris artery (PFA).

Case Example

A 70-year-old female presented for a coronary angiogram because of dyspnea on exertion and abnormal stress test. She had excellent pedal pulses bilaterally. She underwent her procedure via right common femoral artery (CFA) access under ultrasound guidance. The distal third of the right CFA was engaged using a frontal wall stick with a Cook needle (Cook Medical). Using a J-tipped 0.035˝ wire, a 6 Fr sheath was placed into the CFA. There was no percutaneous intervention necessary. The 6 Fr sheath was pulled out at the end of the diagnostic procedure and manual compression was performed, achieving hemostasis in 10 minutes. The patient’s right pedal pulses, however, were lost following manual compression and the leg became cold. 

A peripheral angiogram using a left CFA access was then performed. The mid-left CFA was engaged with a 6 Fr sheath. A pigtail catheter was then advanced to the abdominal aorta and aortography was performed. This showed total occlusion of the right CFA with no flow beyond this vessel (Figure 1A). A 7 Fr short (45 cm) Pinnacle Destination guiding sheath (Terumo Medical) was then placed into the right external iliac via the left CFA. Using an angled 0.035˝ hydrophilic Glidewire (Terumo Medical) advanced over a 5 mm x 40 mm Ultraverse balloon (Bard Peripheral Vascular), the right CFA was crossed into the PFA. Intraluminal positioning was confirmed into the PFA by contrast injection through the balloon lumen (Figure 1B). The balloon was removed and contrast was injected through the destination sheath, revealing a large flap in the right CFA with total occlusion of the right SFA at its origin (Figure 1C). Also, well-developed collaterals were seen from the right PFA retrogradely into the right superficial femoral artery (SFA) (Figure 1D). An attempt to cross the SFA via an antegrade approach was not possible. The obstruction in the right SFA was probably secondary to a dissection flap. Also noted was a small amount of dye crossing over from the right CFA into the right common femoral vein (CFV), indicating the presence of a small arteriovenous (AV) fistula. A transcollateral approach to recanalize the occluded right SFA was then performed. 

The previously placed 7 Fr destination sheath was changed to an 8 Fr destination sheath. Using a 0.014˝ angled Glidewire  and a Turnpike crossing catheter (Vascular Solutions), the collateral vessels from the PFA to the SFA were crossed without significant difficulty into the CFA (Figure 2A). The guidewire was then advanced retrogradely into the contralateral sheath and externalized. Angioplasty to the right CFA and SFA was then completed over the antegrade wire with a 5 mm x 40 mm Ultraverse balloon. Stent deployment was then achieved with an 8 mm x 50 mm Viabahn stent-graft just proximal to the PFA origin to close the AV fistula and treat the CFA dissection. The stent-graft was then postdilated with a 6 mm balloon to 14 atm. Angiography was then performed and the PFA was noted to be occluded and the SFA lumen compressed by a transmural hematoma that migrated distally (Figure 2B). The SFA was dilated successfully with a 5 mm Ultraverse balloon with resolution of the transmural hematoma. The PFA origin, however, was completely obliterated at its origin and could not be identified. Using the collaterals from the right SFA, the PFA was entered retrogradely through the collaterals using the 0.014˝ angled Glidewire and the Turnpike catheter (Figure 2C). The PFA was retrogradely cannulated into the CFA and the guidewire externalized to the contralateral sheath. Angioplasty is then completed antegradely into the PFA with a 5 mm Ultraverse balloon. Stenting was then performed to the proximal PFA with a 6 mm x 80 mm Smart stent. This was postdilated with a 5 mm balloon to 4 atm. Stent deployment was then completed in the right SFA with an 8 mm x 40 mm Smart stent, postdilated with a 6 mm balloon to 14 atm. Selective angiography revealed a widely patent right CFA, right SFA, and right PFA with no distal embolization (Figure 2D). The left CFA sheath was then removed and hemostasis was achieved successfully with a Perclose closure device (Abbott Vascular).

The patient was seen in the office on follow-up 1 month after the procedure. She had no symptoms of limb pain or claudication. Her Duplex arterial ultrasound showed normal flow in her right superficial femoral artery and her ankle-brachial index was 1.01 at rest and 0.91 with exercise. 

Review of the Literature and Discussion

CTOs are present in approximately 30%-40% of patients with symptomatic peripheral arterial disease.¹ Several antegrade techniques and devices have emerged to cross CTOs, but the failure rate has remained approximately 20%.^2,3 Retrograde methods using alternative access sites such as the popliteal, distal SFA, and pedal arteries have been described but do require another arterial entry point, changing patient position (in case of a popliteal access), and potentially increasing access-site complications, particularly with the patient being already anticoagulated.^4-6 A transcollateral approach to recanalize totally occluded SFA via the PFA has been reported in few cases with excellent success and no complications.^7-14 

Table 1 presents a summary of the identified published literature on the treatment of occluded SFAs with the transcollateral retrograde approach. In total, there are 19 patients (21 vessels) treated with this technique in the literature. The success rate was 95.2% and no serious complications have been reported. Various crossing wires (Whisper, Glidewire GT, Cruise wire, Regalia XS, Runthrough, Fielder XT, Terumo Glidewire) and catheters (Quickcross, Sniper2 µ7 microcatheter, Progreat microcatheter, Prominent Microcatheter, FineCross, Corsair, and Turnpike) have been used to cross and navigate the PF collaterals. Although all cases reported in the literature described chronic occlusions, our case was secondary to an acute occlusion from a dissection flap (into the SFA) or a subintimal hematoma (into the PFA). Crossing these vessels was not possible antegradely and in the case of the PFA, there was a flush occlusion at the ostium preventing identification of the vessel origin. Irrespective of the etiology of the total occlusion (chronic or acute), the transcollateral retrograde access appears to be a viable option for recanalizing the SFA or PFA if the antegrade technique fails. Transcollateral techniques have been used successfully in other vascular beds, particularly the coronaries,¹⁵ mesenteric artery,¹⁶ and infrapopliteal vessels.¹⁷ The techniques are similar, and therefore CTO operators will likely find treating SFA-CTO via a transcollateral approach to be an extension of their already acquired skills. We refer the reader to a detailed review of peripheral CTO treatment using a transcollateral approach by Subramanian and Adams.¹³

There are several potential limitations to transcollateral recanalization of the SFA via PFA collaterals. The presence of adequate collaterals is a prerequisite in these patients for this technique to be possible. Collaterals must be of adequate size and reach the SFA, enter the SFA at an angle that allows passing the wire toward the occlusion, and not be excessively long. Also, crossing the collaterals may be challenging but this is more of an acquired skill that will likely improve with experience and by having the right catheters and wires in the angiography laboratory. The operator needs to move slowly and occasionally inject contrast dye antegradely to ensure that the wire remains in the desired collateral. The support catheter has to be advanced over the wire to give the guidewire stability and trackability as it is advanced through the collateral. In addition, advancing a crossing catheter via the collaterals may not be possible and a low-profile balloon can be advanced instead to dilate the occluded segment to allow antegrade access.¹⁴ Furthermore, perforation and bleeding are potential complications that need to be dealt with and operator’s experience in using coils or stent-grafts is likely needed. Finally, loss of collaterals, particularly large ones, may lead to limb ischemia requiring either a new access site with retrograde recanalization or bypass surgery. 

Conclusion

Transcollateral approach to treat the SFA from PFA, or PF from the SFA, appears to be a viable technique with good success rate and low complication rate. This technique could be used as an alternative to retrograde access via popliteal, SFA, or pedal, and could possibly avoid access-site complications. More data are needed to determine the success and feasibility of this technique.  

References

1.    Jacobs DL, Motaganahalli RL, Cox DE, Wittgen CM, Peterson GJ. True lumen re-entry devices facilitate subintimal angioplasty and stenting of total chronic occlusions: Initial report. J Vasc Surg. 2006;43:1291-1296.

2.    Banerjee S, Sarode K, Patel A, et al. Comparative assessment of guidewire and microcatheter vs a crossing device-based strategy to traverse infrainguinal peripheral artery chronic total occlusions. J Endovasc Ther. 2015 May 18 (Epub ahead of print).

3.    Rogers J, Laird J. Overview of new technologies for lower extremity revascularization. Circulation. 2007;116:2072-2085.

4.    Shi W, Yao Y, Wang W, et al. Combined antegrade femoral artery and retrograde popliteal artery recanalization for chronic occlusions of the superficial femoral artery. J Vasc Interv Radiol. 2014;25:1363-1368.

5.    Shin S, Kim S, Ko YG, Hong MK, Jang Y, Choi D. Retrograde distal superficial femoral artery approach in the supine position for chronic superficial femoral artery occlusion. Korean Circ J. 2014;44:184-188.

6.    Ruzsa Z, Nemes B, Bánsághi Z, et al. Transpedal access after failed anterograde recanalization of complex below-the-knee and femoropoliteal occlusions in critical limb ischemia. Catheter Cardiovasc Interv. 2014;83:997-1007.

7.    Pompliano MJ, Adams JL. An uncommon approach through a profunda collateral utilizing a transcollateral approach to revascularize a superficial femoral artery chronic total occlusion. Endovasc Today. Oct 2012:28-30.

8.    Zander T, Gonzalez G, De Alba L, Rivero O, Maynar M. Transcollateral approach for percutaneous revascularization of complex superficial femoral artery and tibioperoneal trunk occlusions. J Vasc Interv Radiol. 2012;23:691-695.

9.    Nakama T, Shibata Y, Kimura T, Fukushima Y, Inoue Y, Kuriyama N. A breakthrough trans-collateral retrograde access for occlusive superficial femoral artery: multi-site access and sheaths insertion (MUSASHI) technique. Cardiovasc Interv Ther. 2015;30:356-361.

10.    Nakamura Y, Komatsu N, Masuda A, Kunii H, Takeda H, Takeishi Y. Successful endovascular treatment of chronic total occlusion of superficial femoral artery using retrograde approach from deep femoral artery. Fukushima J Med Sci. 2014;60:43-46.

11.    Zuffi A, Muller O, Biondi-Zoccai G, et al. Recanalization of a challenging chronic total occlusion of the superficial femoral artery through the profunda femoris using a pure retrograde technique. J Vasc Interv Radiol. 2016;27:1253-1257.

12.    Urasawa K, Sato K, Koshida R, Honma Y. Trans-collateral angioplasty for the treatment of long chronic total occlusions of superficial femoral arteries: a novel wiring technique. J Cardiovasc Surg (Torino). 2014; 55:395-400. 

13.    Subramanian V, Adams GL. Can’t see the forest for the trees: transcollateral crossing of chronic total occlusions. Vasc Dis Manage. 2015;12:E109-E113.

14.    Tai Z. Transcollateral approach for percutaneous revascularization of complex superficial femoral artery chronic total occlusion. J Invasive Cardiol. 2013:25;E96-E100.

15.    Brilakis ES, Karmpaliotis D, Vo MN, et al. Advances in the management of coronary chronic total occlusions. J Cardiovasc Transl Res. 2014;7:426-436.

16.    Robken J, Shammas NW. Treatment of a totally occluded superior mesenteric artery facilitated by retrograde crossing via collaterals from the celiac artery. J Endovasc Ther. 2007;14:745-747.

17.    Fusaro M, Agostoni P, Biondi-Zoccai G. “Trans-collateral” angioplasty for a challenging chronic total occlusion of the tibial vessels: a novel approach to percutaneous revascularization in critical lower limb ischemia. Catheter Cardiovasc Interv. 2008;71:268-272. 

From the Midwest Cardiovascular Research Foundation, Davenport, Iowa.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted September 9, 2016, provisional acceptance given September 19, 2016, final version accepted October 5, 2016.

Address for correspondence: Nicolas W Shammas, MD, MS, FACC, FICA, FSCAI, FSVM, President and Research Director, Midwest Cardiovascular Research Foundation,

1622 East Lombard Street, Davenport, IA 52803. Email: shammas@mchis.com