A novel technique to reach the contralateral iliac artery in Leriche syndrome

Introduction

Leriche syndrome is an atheromatous occlusion of the infrarenal aorta, common iliac arteries, or both. ¹ This chronic disease progression often takes decades and has the propensity to affect males in their third to sixth decade of life. ¹ Patients often have risk factors such as hypertension, hyperlipidemia, diabetes mellitus, and smoking. Leriche syndrome presents with intermittent lower extremity vascular claudication, impotence, and weak or absent femoral pulses.^1,2

The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) stratified aortoiliac lesions considering length, grade of occlusion, and position. The endovascular approach is more suitable for lesions classified TASC A and B and open surgery for lesions TASC C and D. ³ The patency rate of open surgery can reach over 90% at 5 years, while endovascular treatment has a patency rate of 72% at 4 years. ⁴ However, open surgery has higher complication rates and mortality. Therefore, several endovascular treatment options have been developed for elderly and fragile patients. Nevertheless, endovascular management is limited by the challenges of crossing highly calcified lesions. The leading cause of technical failure is the inability to reach the true lumen beyond an occluded vascular segment. There are several devices to reach the true lumen. ⁵ However, these devices have challenges and considerably increase the cost. We hereby present a novel and inexpensive technique to reach the contralateral iliac artery in Leriche syndrome.

Case report

A 45-year-old male patient with a history of coronary artery disease was admitted to the cardiology clinic with complaints of bilateral lower extremity claudication. Physical examination revealed absent femoral pulses and decreased ankle-brachial index (0.4). Computed tomography angiography (CTA) unearthed the TASC D Leriche syndrome (Figures 1(a) and (b)). Because the patient refused surgery, he was scheduled for percutaneous transluminal angioplasty (PTA). Firstly, a 0.035 inch, straight, hydrophilic guidewire was crossed from the right common iliac artery to the true lumen of the distal aorta. Secondly, we attempted to cross the left occlusion; however, the guidewire couldn’t reach the true lumen. For this reason, we used Asahi Gladius® 0.014 inch guidewire, Asahi Halberd® 0.014 inch guidewire, and Asahi Astato® 30 0.018 inch guidewire, respectively. Unfortunately, several attempts with these guidewires failed to cross the lesion. Afterward, we decided to dilate the right side of the occlusion with a 5 × 200 mm peripheral angioplasty balloon retrogradely, and then a 6 Fr Judkins right (JR) guiding catheter was advanced from the right side to reach the ostium of the left common iliac artery, anterogradely. However, the guidewire couldn’t penetrate due to the sharp angle and insufficient support. Subsequently, a sterile non-absorbable suture was stitched up to the tip of the JR guiding catheter. One part of the suture was left long, and the support was provided by keeping it slightly taut like a lasso from the outside of the right femoral sheath (Figures 1(c) and (d), Video 1 and 2). The hydrophilic guidewire was crossed from the occluded left common iliac artery (Figure 1(e)), and a 5 × 200 mm peripheral angioplasty balloon was performed from the right to the left common iliac artery (Figure 1(f)). The true lumen of the aorta was easily reached by entering from the left femoral artery, and kissing balloons were performed (Figure 1(g)). Finally, bilateral balloon expandable stents were implanted (Figure 1(h), Video 3). At a six-month follow-up, the patient was completely asymptomatic.OPEN IN VIEWER

Discussion

Surgical revascularization has been the treatment of choice for complicated iliac artery lesions. The outcomes are favorable, and surgery is usually superior in target lesion revascularization and patency rates, especially in the early years of endovascular interventions, but it still has higher perioperative mortality rates. ⁶ In addition, these patients are often elderly, with multiple comorbidities and high frailty scores, and thus surgical interventions are not always a feasible choice. ⁶ Endovascular interventions are rapidly evolving and surpassing most limitations of open surgery.

Endovascular revascularization is the most anatomical approach and is generally considered the best option for aortoiliac tract stenosis or occlusion. ⁷ Intraluminal crossing of an iliac artery lesion is traditionally utilized as the first approach but failed in approximately 20% of cases, despite the increasing experience of endovascular operators. ⁸ For this reason, there are some special techniques. One of the most preferred technique is percutaneous intentional extraluminal revascularization (PIER), performed with a hydrophilic guidewire and a support catheter, which can cross the lesion by dissecting the subintimal space, passing through the occluded area and crossing back distally in the true lumen. ⁶ However, PIER is not a panacea, especially when the lesion is chronic, lengthy, and heavily calcified. As a result, PIER still fails in up to 25% of cases, with the most significant difficulty usually being how to reenter the true lumen. ⁹ Another common reason for failure is re-entry, which can lead to severe complications (in retrograde iliac crossing, there is always the risk for aorta damage, and in anterograde crossing, for internal iliac damage). ⁷

Re-entry devices (REDs) are another option to cross the occluded segment by facilitating PIER. The advantages of these devices are increasing the chance of success, crossing to the true lumen in a short time, decreasing the radiation exposure, and limiting the extension of the dissected segment. However, complications can still happen. In a review, Kokkinidis et al. ¹⁰ reported the complication rate was 6.9% which was very similar to the complication rate in the PIER. Other common problems encountered in RED use include the steep learning curve and the high cost. As a result, REDs are not always suitable for most clinics due to the high cost. Therefore, developing intraluminal crossing and PIER techniques may increase the chance of success and reduce the cost considerably.

The retrograde homolateral approach is frequently preferred when considering the system’s stiffness. Even though the contralateral anterograde approach has been described, difficulties in providing strong support result in failure to fall into the true lumen. In this case, although both hydrophilic and stiff wires were used, retrograde access to the true lumen could not be achieved. After that, we attempted to cross the lesion from the contralateral iliac artery with a novel guide catheter support technique. On the other hand, some potential complications may occur with this new technique. The most prominent complication is iliac artery dissection due to the taut suture line, which may result in stenting of the iliac artery. The other potential complication is the entrapment of the guiding catheter and sutures into the sheath. However, this complication can be overcome by using larger sheaths. Another rare but serious complication is vessel perforation. This may cause retroperitoneal bleeding, which, if not treated early, may bring fatal consequences.

Conclusion

Endovascular treatment for Leriche syndrome is a valuable alternative to surgery, especially in high-risk patients. Intraluminal crossing, PIER, and REDs are the most preferred techniques. However, while there is a little significant difference in success rates between these techniques, there is a substantial difference in costs. Increasing the technical success of intraluminal crossing and PIER leads to an apparent reduction in cost. Finally, we performed a novel, inexpensive, and easily applicable technique to increase the support of the guiding catheter, and this technique may increase the success rates.

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