The “Direct Tip Injection in Occlusive Lesions (DIOL)” Fashion.

Abstract Background: The successful intervention for peripheral artery disease is limited by complex chronic total occlusions (CTOs). During CTO wiring, without the use of intravascular or extravascular ultrasound, the guidewire position is unclear, except for calcified lesions showing the vessel path. To solve this problem, we propose a novel guidewire crossing with plaque modification method for complex occlusive lesions, named the “Direct tip Injection in Occlusive Lesions (DIOL)” fashion.Main text: The “DIOL” fashion utilizes the hydraulic pressure of tip injection with a general contrast media through a microcatheter or an over-the-wire balloon catheter within CTOs. The purposes of this technique are 1) to visualize the “vessel road” of the occlusion from expanding a microchannel, subintimal, intramedial, and periadventitial space with contrast agent and 2) to modify plaques within CTO to advance CTO devices safely and easily. This technique creates dissections by hydraulic pressure. Antegrade-DIOL may create dissections which extend to and compress a distal lumen, especially in below-the-knee arteries. A gentle tip injection with smaller contrast volume (1-2 ml) should be used to confirm the tip position which is inside or outside of a vessel. On the other hand, retrograde-DIOL is used with a forceful tip injection of moderate contrast volume up to 5-ml to visualize vessel tracks and to modify the plaques to facilitate the crossing of CTO devices. Case-1 involved a severe claudicant due to right superficial femoral artery occlusion. After the conventional bidirectional subintimal procedure failed, we performed two times of retrograde-DIOL fashion, and the bidirectional subintimal planes were successfully connected. After two stents implantation, a sufficient flow was achieved without complications and restenosis for two years. Case-2 involved multiple wounds in the heel due to ischemia caused by posterior tibial arterial occlusion. After the conventional bidirectional approach failed, retrograde-DIOL was performed and retrograde guidewire successfully crossed the CTO, and direct blood flow to the wounds was obtained after balloon angioplasty. The wounds heeled four months after the procedure without reintervention.Conclusions: The DIOL fashion is a useful and effective method to facilitate CTO treatment.

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The “Direct tip injection in occlusive lesions (DIOL)” fashion

CVIR Endovascular ◽

10.1186/s42155-021-00276-w ◽

2021 ◽

Vol 4 (1) ◽

Author(s):

Takuya Haraguchi ◽

Tsutomu Fujita ◽

Yoshifumi Kashima ◽

Masanaga Tsujimoto ◽

Tomohiko Watanabe ◽

...

Keyword(s):

Balloon Catheter ◽

Arterial Occlusion ◽

Artery Occlusion ◽

Hydraulic Pressure ◽

Chronic Total Occlusions ◽

Below The Knee ◽

Contrast Volume ◽

Artery Disease ◽

Tip Position ◽

Tip Injection

Abstract Background The successful intervention for peripheral artery disease is limited by complex chronic total occlusions (CTOs). During CTO wiring, without the use of intravascular or extravascular ultrasound, the guidewire position is unclear, except for calcified lesions showing the vessel path. To solve this problem, we propose a novel guidewire crossing with plaque modification method for complex occlusive lesions, named the “Direct tip Injection in Occlusive Lesions (DIOL)” fashion. Main text The “DIOL” fashion utilizes the hydraulic pressure of tip injection with a general contrast media through a microcatheter or an over-the-wire balloon catheter within CTOs. The purposes of this technique are 1) to visualize the “vessel road” of the occlusion from expanding a microchannel, subintimal, intramedial, and periadventitial space with contrast agent and 2) to modify plaques within CTO to advance CTO devices safely and easily. This technique creates dissections by hydraulic pressure. Antegrade-DIOL may create dissections which extend to and compress a distal lumen, especially in below-the-knee arteries. A gentle tip injection with smaller contrast volume (1–2 ml) should be used to confirm the tip position which is inside or outside of a vessel. On the other hand, retrograde-DIOL is used with a forceful tip injection of moderate contrast volume up to 5-ml to visualize vessel tracks and to modify the plaques to facilitate the crossing of CTO devices. Case-1 involved a severe claudicant due to right superficial femoral artery occlusion. After the conventional bidirectional subintimal procedure failed, we performed two times of retrograde-DIOL fashion, and the bidirectional subintimal planes were successfully connected. After two stents implantation, a sufficient flow was achieved without complications and restenosis for two years. Case-2 involved multiple wounds in the heel due to ischemia caused by posterior tibial arterial occlusion. After the conventional bidirectional approach failed, retrograde-DIOL was performed and retrograde guidewire successfully crossed the CTO, and direct blood flow to the wounds was obtained after balloon angioplasty. The wounds heeled four months after the procedure without reintervention. Conclusions The DIOL fashion is a useful and effective method to facilitate CTO treatment.

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Balloon-Assisted Retrograde Puncture of Distal Vessels in Patients Unsuitable for a Conventional Transpedal Approach

Journal of Endovascular Therapy ◽

10.1177/15266028211068761 ◽

2022 ◽

pp. 152660282110687

Author(s):

August Ysa ◽

Marta Lobato ◽

Ana M. Quintana ◽

Leire Ortiz de Salazar ◽

Roberto Gómez ◽

...

Keyword(s):

Arterial Occlusion ◽

Chronic Total Occlusions ◽

Tibial Artery ◽

Below The Knee ◽

Angioplasty Balloon ◽

Low Profile ◽

Loop Technique ◽

The Wire ◽

Technique Failure

Purpose: To describe a novel bailout technique to approach below-the-knee chronic total occlusions after a failed bidirectional recanalization attempt using the plantar loop maneuver in patients who are poor candidates for a retrograde puncture. Technique: After a failure of recanalization of the opposite tibial artery using the plantar loop maneuver, an assisted direct retrograde transpedal approach can be performed regardless of poor vessel caliber or even arterial occlusion. After crossing the plantar arch, a low profile angioplasty balloon is used as a landmark for the pedal puncture and to give guidance for the wire advancement from the new access. Conclusion: A balloon-assisted retrograde transpedal approach may be considered for below-the-knee recanalization after standard plantar loop technique failure in patients who are not candidates for conventional retrograde puncture.

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Procedural comparison of a standard PTA balloon for fistula and graft maintenance procedures with the novel Chameleon™ PTA balloon catheter

The Journal of Vascular Access ◽

10.1177/1129729820979479 ◽

2020 ◽

pp. 112972982097947

Author(s):

Joel Crawford ◽

Antonios Gasparis ◽

Pamela Kim ◽

Manish Jotwani ◽

Satyaki Banerjee ◽

...

Keyword(s):

Balloon Catheter ◽

Fluoroscopy Time ◽

Control Group ◽

The Novel ◽

Procedure Time ◽

Injection Port ◽

Contrast Volume ◽

Group A ◽

Artery Disease ◽

Group B

Introduction: The incidence of cephalic arch (CA) and central venous (CV) stenosis has been reported in the range of 30% in the literature. The purpose of this study is to compare contrast use, fluoroscopy time, and procedure time between standard imaging by injection of contrast through the access sheath versus injection of contrast through a novel PTA balloon with an integrated injection port. Methods: A multi-centered, retrospective evaluation of consecutive patients treated for CA and CV stenosis was performed. Data captured included demographics, co-morbidities, lesion characteristics/location, procedural details, volume of contrast used, fluoroscopy time, and procedure time. The control group was imaged and treated using standard practice with pre and post imaging performed through the sheath and intervention using standard PTA balloon. Imaging and treatment were performed using the Chameleon™ PTA catheter in the treatment arm. Results: A total of 68 consecutive patients were included. There were 34 patients in Group A and 34 patients in Group B. Average age was 65.2 versus 66.5 ( p = 0.284), respectively. There were no significant gender differences between groups. Prevalence of co-morbidities of hypertension, coronary artery disease, and diabetes was similar to national rates in both groups. Contrast volume, fluoroscopy time, and procedure time in Group B were significantly less when compared by multiple regression to Group A, correcting for potential confounders ( p = 0.0001, 0.0180, and 0.0008, respectively). Conclusion: Use of a PTA balloon with an integrated injection port shows potential for significant reduction in contrast dose, fluoroscopy time, and procedure time.

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Patency of the arterial pedal–plantar arch in patients with chronic kidney disease or diabetes mellitus

Therapeutic Advances in Cardiovascular Disease ◽

10.1177/1753944718756605 ◽

2018 ◽

Vol 12 (5) ◽

pp. 145-153 ◽

Cited By ~ 9

Author(s):

Axel Haine ◽

Alan G. Haynes ◽

Andreas Limacher ◽

Tim Sebastian ◽

Wuttichai Saengprakai ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Estimated Glomerular Filtration Rate ◽

Artery Occlusion ◽

Peroneal Artery ◽

Vessel Occlusion ◽

Unadjusted Odds Ratio ◽

Below The Knee ◽

Control Versus ◽

Artery Disease

Background: Patency of the pedal-plantar arch limits risk of amputation in peripheral artery disease (PAD). We examined patients without chronic kidney disease (CKD)/diabetes mellits (DM) [PAD-control], those with DM without CKD, and those with CKD without DM. Method: Uni- and multivariate logistic regression was used to assess association of CKD with loss of patency of the pedal–plantar arch and presence of tibial or peroneal vessel occlusion. Multivariate models adjusted for age, sex, hypertension, hyperlipidemia and smoking. Results: A total of 419 patients were included [age 75.2 ± 10.3 years, 288 (69%) male]. CKD nearly doubled the unadjusted odds ratio (OR) for loss of patency of the pedal–plantar arch. After adjustment, association remained significant for severe CKD [estimated glomerular filtration rate (eGFR) ≤ 29 ml/min compared with eGFR ≥ 60 ml/min, adjusted (adj.) OR 8.24 (95% confidence interval {CI} 0.99–68.36, p = 0.05)]. CKD was not related to risk of tibial or peroneal artery occlusion [PAD-control versus CKD, adj. OR 1.09 (95% CI 0.49–2.44, p = 0.83)] in contrast to DM [PAD–control versus DM, adj. OR 2.41 (95% CI 1.23–4.72, p = 0.01), CKD versus DM, adj. OR 2.21 (95% CI 0.93–5.22); p = 0.07)]. Conclusions: Below the knee (BTK) vascular pattern differs in patients with either DM or CKD alone. Severe CKD is a risk factor for loss of patency of the pedal–plantar arch.

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Drug-Coated Balloons Applications in Interventional Cardiology

Current Pharmaceutical Design ◽

10.2174/1381612824666171227212112 ◽

2018 ◽

Vol 24 (4) ◽

pp. 397-401

Author(s):

Gianluca Rigatelli ◽

Marco Zuin

Keyword(s):

Interventional Cardiology ◽

Vessel Diameter ◽

Peripheral Artery ◽

Small Vessels ◽

Below The Knee ◽

Stent Restenosis ◽

Normal Vessel ◽

Drug Eluting ◽

Artery Disease ◽

And Function

Backgrounds: Drug coated balloons (DCBs) are new on stented-based anti-proliferative drug delivery systems, recently introduced in interventional cardiology. Their primary aim is to transfer an anti-proliferative drug to reduce the subsequent neo-intima hyperplasia and to maintain the normal vessel diameter and function. Methods: A review of the most recent influential studies about DCBs in all the fields of interventional cardiology has been performed. Results: As demonstrated by different studies, DCBs have different theoretical advantages over Drug Eluting Stents (DESs), especially for the treatment of some endovascular lesions, as In-Stent Restenosis (ISR), coronary bifurcations, small vessels disease and peripheral artery disease at femoropopliteal and below the knee sites. Conclusion: Despite the need of further studies are needed to elucidate the optimal use of DCBs their current use in interventional cardiology appears promising.

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Influence of diabetes on diagnostic performance of computed tomography angiography of the calf arteries in acute limb ischemia

Acta Radiologica ◽

10.1177/02841851211006918 ◽

2021 ◽

pp. 028418512110069

Author(s):

Talha Butt ◽

Leena Lehti ◽

Jan Apelqvist ◽

Anders Gottsäter ◽

Stefan Acosta

Keyword(s):

Computed Tomography ◽

Computed Tomography Angiography ◽

Diagnostic Performance ◽

Intraclass Correlation ◽

Arterial Occlusion ◽

Limb Ischemia ◽

Arterial Disease ◽

Diabetic Patients ◽

Acute Limb Ischemia ◽

Below The Knee

Background Patients with diabetes mellitus (DM) have a more extensive distal arterial occlusive disease compared to non-diabetic patients. Diagnostic imaging is a necessity to identify the location and extent of the arterial occlusion in acute limb ischemia (ALI). Computed tomography angiography (CTA) is the most commonly used modality and the diagnostic performance with CTA of calf arteries may be questioned. Purpose To evaluate diagnostic performance of CTA of calf arteries in ALI and to compare patients with and without DM. Material and Methods All thrombolytic treatments performed during 2001–2008 in patients with ALI were included. Initial digital subtraction angiography (DSA) and CTA of all patients were classified according to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) below-the-knee arteries and compared to CTA. Two raters assessed the CTA images independently. Inter-rater reliability was expressed as intraclass correlation (ICC) with 95% confidence intervals (CI). Results Patients with (n = 23) and without (n = 85) DM had lower ( P = 0.006) glomerular filtration rate. ICC between CTA and DSA was 0.33 (95% CI –0.22 to 0.56) and 0.71 (95% CI 0.38–0.68) in patients with and without DM, respectively. Sensitivity with CTA for TASC D lesions in patients with and without DM was 0.14 (95% CI –0.12 to 0.40) and 0.64 (95% CI 0.48–0.80), respectively. Conclusion The sensitivity of CTA for assessment of infra-popliteal TASC D lesions in patients with ALI was not acceptable in patients with DM in contrast to those without DM. Another imaging option at present times should be considered for patients with DM.

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Mechanical Unloading Properties of Axial Flow Pumps and their Effect on Myocardial Stunning

The International Journal of Artificial Organs ◽

10.1177/039139889501801204 ◽

1995 ◽

Vol 18 (12) ◽

pp. 766-771 ◽

Cited By ~ 5

Author(s):

F. R. Waldenberger ◽

B. Meyns ◽

P. Wouters ◽

E. De Ruyter ◽

E. Pongo ◽

...

Keyword(s):

Coronary Artery ◽

Myocardial Stunning ◽

Myocardial Dysfunction ◽

Axial Flow ◽

Coronary Artery Occlusion ◽

Artery Occlusion ◽

Wall Thickening ◽

Myocardial Wall Motion ◽

Mechanical Unloading ◽

Artery Disease

Postischemic myocardial dysfunction affects morbidity and mortality in patients with coronary artery disease. It is known that mechanical unloading of the left heart ventricle can positively influence postischemic myocardial dysfunction. In this respect we tested two miniaturised axial flow pumps, i.e. the 14-F and the 21-F Hemopump®. An experimental study was carried out on 30 open chest sheep where regional myocardial wall motion was followed using sonomicrometry in a preparation of transient coronary artery occlusion. Only the larger 21-F Hemopump® showed hemodynamically significant unloading of the left ventricle. Furthermore, as far as stunning is concerned, systolic wall thickening recovered better when this type of pump was used during reperfusion. Also postejection thickening, which is an indication of diastolic postischemic dysfunction, is reduced significantly in the postischemic area (ANOVA, p<0.05). Thus, the 21F Hemopump®, but not the 14F Hemopump®, provides adequate mechanical unloading in order to beneficially influence myocardial stunning.

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Acute compensation to abrupt occlusion of rat femoral artery is prevented by NO synthase inhibitors

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.1994.267.6.h2523 ◽

1994 ◽

Vol 267 (6) ◽

pp. H2523-H2530 ◽

Cited By ~ 4

Author(s):

J. L. Unthank ◽

J. C. Nixon ◽

M. C. Dalsing

Keyword(s):

Femoral Artery ◽

Arterial Occlusion ◽

Artery Occlusion ◽

No Synthase ◽

Artery Blood Flow ◽

Relaxing Factor ◽

Femoral Artery Occlusion ◽

Before And After ◽

Endothelium Derived Relaxing Factor ◽

Oxide Synthase

The hemodynamic significance of endothelium-derived relaxing factor (EDRF)-mediated mechanisms in vascular responses to abrupt rat femoral artery occlusion was investigated. Temporary arterial occlusion was produced before and after inhibition of nitric oxide synthase by N omega-nitro-L-arginine methyl ester (L-NAME) or NG-monomethyl-L-arginine (L-NMMA). Iliac artery blood flow and arterial pressures proximal and distal to the occlusion were measured. Normal vascular compensation included a return of resistance to preocclusion levels and a rise in distal pressure to a plateau within 5 min postocclusion. After treatment with L-NAME and L-NMMA, postocclusion resistance remained elevated by 53 and 36%, respectively. Collateral dilation after occlusion, as indicated by the rise in distal pressure, was prevented by L-NAME but not L-NMMA. Increases in adrenergic tone and mean arterial pressure by phenylephrine did not prevent compensation, suggesting the effects of L-NAME and L-NMMA did not result from elevated sympathetic activation or pressure. The results are consistent with the hypothesis that the stimulated release of endothelium-derived relaxing factor mediates the acute vascular compensation to abrupt arterial occlusion.

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