Outcomes of non-flow-limiting spiral dissection after drug-coated balloon angioplasty for de novo femoropopliteal lesions.

BACKGROUND: Whether drug-coated balloon (DCB) angioplasty would be effective in spiral dissection (SD) lesions with no flow impairment has been thoroughly investigated. AIMS: The present study sought to assess the clinical outcomes of non-flow-limiting SD after DCB angioplasty for de novo femoropopliteal lesions in patients with symptomatic lower extremity artery disease. METHOD: This single-center retrospective study enrolled 497 patients with non-flow-limiting SD (n = 92) or non-SD (n = 405) without bailout stenting. The primary endpoint was 1-year primary patency, with the secondary endpoints including freedom from target lesion revascularization (TLR), major adverse limb event (MALE), all-cause death, and 30-day restenosis. RESULTS: The 1-year primary patency and freedom from TLR were significantly lower in the SD group than in the non-SD group (69.8% vs. 83.3%, p = 0.004; 78.7% vs. 93.0%, p = 0.007, respectively). The SD group had a higher incidence of MALE and 30-day restenosis than the non-SD group (24.6% vs. 11.9%, p = 0.001; 4.3% vs. 0.5%, p = 0.002, respectively). All-cause death was comparable. One-year restenosis after SD was associated with chronic limb-threatening ischemia (CLTI) (hazard ratio, 3.36 [95% confidence interval, 1.21-9.36]; p = 0.020), TASC Ⅱ D (hazard ratio, 3.97 [95% confidence interval, 1.02-15.52]; p = 0.047), and residual stenosis ≥50% (hazard ratio, 4.92 [95% confidence interval, 1.01-23.94]; p = 0.048). The incidence of restenosis after SD increased with the number of these risk factors. CONCLUSIONS: Despite normal antegrade flow, the 1-year primary patency rate after DCB angioplasty for de novo femoropopliteal lesions was significantly lower in lesions with SD than those without SD. CLTI, TASC II D, and residual stenosis ≥50% were risk factors associated with 1-year restenosis after DCB angioplasty for non-flow-limiting SD lesions.

Wire ThRoUgh Snare Twice (Wire TRUST) technique: A novel method to grasp a lead with inaccessible ends as a supportive femoral approach for transvenous lead extraction.

INTRODUCTION: Transvenous lead extraction (TLE) is a crucial procedure for managing cardiac implantable electronic devices. The use of a combined superior and femoral approach has been found to enhance the success rate of TLE. This report introduces a novel technique, named "Wire ThRoUgh Snare Twice" (Wire TRUST), for effectively grasping a lead without a free end during TLE. METHOD: The Wire TRUST technique was applied in a case involving a 49-year-old male patient requiring TLE due to electrical artifact on the right ventricular (RV) lead, replacement of the RV lead, and pacemaker generator exchange. The Wire TRUST technique involved the insertion of a 4-Fr pigtail catheter and a 6-Fr snare catheter through the 14-Fr sheath inserted from the right common femoral vein. The 4-Fr pigtail catheter was hooked to the RV lead under multidirectional fluoroscopic guidance in the right atrium. The 0.014-in. guidewire was advanced through the pigtail catheter, crossing the RV lead until reaching the inferior vena cava. Subsequently, the distal end of the 0.014-in. guidewire was captured using a snare and pulled, facilitating externalization of the guidewire. After externalization, both ends of the 0.014-in. guidewire were passed through the snare outside the body and reinserted into the 14-Fr sheath. By simultaneously advancing and closing the snare while applying tension to the 0.014-in. guidewire, a secure grip on the lead without free ends was achieved. RESULTS: The Wire TRUST technique enabled successful lead extraction and replacement without any complications. The technique facilitated the co-axial alignment of the powered sheath with the RV lead, ensuring safe and efficient extraction. CONCLUSION: The Wire TRUST technique presents a novel and effective approach for grasping leads with inaccessible ends during TLE.

Coil Embolization for Coronary Artery Perforation: A Retrospective Analysis of 110 Patients.

OBJECTIVE: Coil embolization (CE) for coronary artery perforation (CAP) has not been thoroughly evaluated. This study aimed to evaluate the extent of myocardial damage and impact on cardiac function after CE for CAP. METHODS: A total of 110 consecutive patients treated with CE for CAP were retrospectively identified. The degree of myocardial damage and impact on cardiac function were evaluated. RESULTS: Forty-nine (44.5%) cases involved chronic total occlusions. A guidewire was the cause of perforation in 97 (88.2%) patients. The success rate of CE was 98.2%. Almost all patients were prescribed either antiplatelet drugs or anticoagulant medication or both. Patients with perforation types III and IV were found to be prone to creatinine kinase (CK) elevation and epicardial main vessel perforation, thereby causing myocardial damage. No changes were noted in the ejection fraction (EF) in patients with type V distal perforation and collateral channel perforation, while patients with perforation of the epicardial main vessel may show impaired cardiac function afterward. CONCLUSIONS: CE is safe and effective for treating CAP, especially when collateral channels and distal vessels are involved. Meanwhile, efforts should be taken to prevent CAP in epicardial main vessels since it may be difficult to treat with CS and cause myocardial damage when bailed out with CE leading to vessel sacrifice. We found that it was not necessary to change the anticoagulant regimen after CE owing to its ability to achieve robust hemostasis.

Repeat drug-coated balloon angioplasty for femoropopliteal lesions: 12-month results from a retrospective observational study.

BACKGROUND: The clinical implications of restenosis after drug-coated balloon (DCB) treatment remain unclear. We compared the clinical outcomes between DCB angioplasty for restenosis and de novo femoropopliteal artery lesions. This single-center retrospective study included 571 patients (737 limbs) who underwent either repeat (54 patients, 64 limbs) or de novo DCB (517 patients, 673 limbs) without bailout stenting. After propensity score matching, 49 matched pairs were analyzed. The primary endpoint was the 1-year primary patency, with secondary endpoints including the freedom from target lesion revascularization (TLR), major adverse limb events (MALE), and early restenosis. Predictors of restenosis were identified using multivariable Cox regression analysis. RESULTS: The repeat-DCB group displayed significantly lower rates of 1-year primary patency and freedom from TLR compared to those of the de novo-DCB group (50.1% vs. 77.4%, p = 0.029 and 54.9% vs. 83.6%, p = 0.0.44, respectively). No significant differences were observed in early restenosis or MALE (10.7% vs. 5.9%, p = 0.455 and 48.3% vs. 73.4%, p = 0.055, respectively). Restenosis after DCB angioplasty was associated with repeat DCB (hazard ratio [HR], 5.13; 95% confidence interval [CI], 1.43-18.4; p = 0.012) and small vessel size of < 4.5 mm (HR, 6.25; 95% CI, 1.17-33.4; p = 0.032). Furthermore, restenosis after repeat DCB angioplasty was associated with the Peripheral Artery Calcification Scoring System (PACSS) grade 4 (HR, 4.20; 95% CI, 1.08-16.3; p = 0.038), small vessel size of < 4.5 mm (HR, 9.44; 95% CI, 1.21-73.7; p = 0.032), and intravascular ultrasound (IVUS) use (HR, 0.05; 95% CI, 0.01-0.44; p = 0.007). CONCLUSIONS: The 1-year primary patency rate following repeat DCB angioplasty for femoropopliteal lesions was notably lower than that of DCB treatment for de novo lesions. Repeat DCB strategy was associated with an increased risk of patency loss. Regarding repeat restenosis after DCB treatments, PACSS grade 4 calcification and small vessel diameter of < 4.5 mm were associated with an increased risk of restenosis, whereas IVUS use correlated with a decreased risk of restenosis.

Rendezvous-PIERCE technique: establishing a channel through severe calcification in infrainguinal arterial lesions using needle rendezvous.

BACKGROUND: Severe calcification often prevents device passage and balloon expansion in cases of lower extremity artery disease. To address this limitation, we introduced a novel calcium modification technique called Rendezvous-PIERCE (R-PIERCE). METHODS: A needle was inserted in a retrograde manner and advanced to touch the tip of an antegrade guidewire within the lesion. Then, the guidewire was advanced into the lumen of the needle to achieve partial guidewire externalization, also known as needle rendezvous. The needle was then introduced over the externalized guidewire under wire tension and repeatedly rotated and advanced across the lesion to modify calcified intimal plaques. Notably, this technique can be applied in the opposite direction. RESULTS: Case 1 involved a 68-year-old male with a calcified occlusion of the anterior tibial artery. An antegrade guidewire reached the midpoint of the occlusion; however, microcatheters and balloons could not pass through the proximal calcification. Therefore, R-PIERCE was used to modify uncrossable lesions. An antegrade 2.5-mm balloon crossed and dilated the lesion, achieving hemostasis at the needle insertion site. The antegrade guidewire successfully crossed the entire lesion and was dilated by the 2.5-mm balloon. Final angiography demonstrated successful flow. In Case 2, an 80-year-old male had a calcified femoropopliteal occlusion. An antegrade guidewire was advanced into the distal superficial femoral artery (SFA); however, no device could follow it. R-PIERCE was performed to modify the calcification from the distal to the medial SFA. The antegrade balloon successfully crossed and dilated obstructed lesions. Furthermore, the antegrade guidewire crossed the entire lesion, and the antegrade balloon was dilated. Final angiography revealed a successful flow without complications. CONCLUSIONS: R-PIERCE is useful for modifying complex calcified lesions during the wiring of occlusive lesions.

Successful transvenous retrieval of an electrode ring dislodged from a novel visualized steerable sheath by inflation of a balloon inside the ring.

The VIZIGO sheath (Biosense Webster, Irvine, CA, USA) is used for catheter ablation (CA) of atrial arrhythmia. In this case report, we describe a complication associated with the VIZIGO sheath and present a successful bailout method. An 82-year-old woman with paroxysmal atrial fibrillation (AF) and atrial tachycardia (AT) was referred to our hospital after experiencing palpitations for 6 months. She underwent CA using the VIZIGO sheath and a fixed Swartz sheath (St. Jude Inc., St. Paul, MN, USA). Pulmonary vein isolation and left atrial posterior wall isolation were performed to address AF and AT. Following ablation, the Swartz sheath was removed; however, the VIZIGO sheath showed resistance to removal. A wire was inserted into the VIZIGO sheath for removal, but the distal electrode ring detached in the vessel. To retrieve the electrode ring, a Mustang over-the-wire angioplasty balloon was dilated inside the ring and withdrawn with the ring. After venography and confirmation of a hemostatic seal, the ablation procedure was completed. The patient experienced postoperative anemia, which was resolved by erythrocyte transfusion. No further paroxysmal AF or AT occurred during the 1-year follow-up. In conclusion, the VIZIGO sheath's distal electrode ring may become detached during CA, and the detached ring can be successfully retrieved using our original bailout technique. Learning objective: This case report highlights the unique complication of electrode ring detachment associated with the novel visualized steerable sheath (VIZIGO; Biosense Webster, Irvine, CA, USA) during catheter ablation procedures and presents the successful technique as a bailout method for retrieving the dislodged ring. The technique involves dilating a non-compliant over-the-wire angioplasty balloon inside the ring and withdrawing it along with the detached ring.

The ViaHole technique: a novel approach for recanalizing major side branch occluded by Viabahn stent-graft.

INTRODUCTION: In managing arterial rupture, stent-graft implantation may cause limb ischemia by crossing a major branch for hemostasis. The ViaHole technique could circumvent a major branch occlusion. MATERIALS AND METHODS: The process involved advancing retrograde devices into an occluded major branch by the stent-graft implantation to reach the outer surface of the stent-graft, puncturing the stent-graft with a 20-gauge needle to touch the retrograde device, manipulating the guidewire through the needle hole and externalizing it, advancing the microcatheter into the proximal lumen, catching the microcatheter using an antegrade 4-Fr catheter, inserting an antegrade guidewire into the retrograde microcatheter to cross the stent-graft hole, dilating the lesion and stent-graft hole using a 3.0-mm balloon, and ensuring hemostasis at the puncture site. RESULTS: A 72-year-old male with a history of stent-grafted treatment for right popliteal aneurysm presented with acute limb ischemia (ALI). The occlusion spanned distal superficial femoral artery to the below-the-knee arteries. Hemostasis was achieved after an unintentional rupture of the proximal posterior tibial artery during surgical thrombectomy by implanting endoluminal stent-grafts instead of surgical bypass due to no distal anastomosis site. However, recurrent ALI occurred three months later. Surgical bypass was again deemed unfeasible due to no run-off. Unsuccessful recanalization attempts of the bilateral tibial arteries led us to perform the ViaHole technique to recanalize the peroneal artery occlusion. Finally. successful revascularization was achieved, and 1-year patency was confirmed. CONCLUSIONS: The ViaHole technique may be valuable for revascularizing a major side branch occluded by stent-graft implantation.

Propensity score-matched analysis of six-month outcomes of paclitaxel-coated balloons combined with UltraScore balloons versus conventional scoring balloons for femoropopliteal lesions.

PURPOSE: Combination angioplasty with paclitaxel-coated balloons (PCBs) and conventional scoring balloons for femoropopliteal lesions has demonstrated satisfactory results, even for complex lesions. The UltraScore balloon (Becton Dickinson, New Jersey, USA), which has a maximum length of 300 mm, has two longitudinal 0.010-inch stainless steel wires and is a new treatment option for complex femoropopliteal lesions. However, no studies have evaluated the effect of the UltraScore balloon on femoropopliteal lesions. This study aimed to compare the clinical efficacy of angioplasty over a six-month period using UltraScore balloons versus conventional scoring balloons for the treatment of atherosclerotic femoropopliteal lesions with PCBs. METHODS: A retrospective single-center observational study enrolled 272 patients who underwent PCB angioplasty combined with an UltraScore balloon (n = 58) or conventional scoring balloon (n = 214) without bailout stenting. Propensity score matching was used to minimize intergroup differences in baseline characteristics, and six-month outcomes were compared between the two groups. The primary endpoint was a technical success (i.e., residual angiographic stenosis of <30% with non-severe dissection). The secondary endpoints were the incidences of periprocedural complications, restenosis, and target lesion revascularization (TLR). RESULTS: After propensity score matching, 50 matched pairs of patients were selected for analysis. The UltraScore group had a significantly longer vessel length (192.8 ± 94.9 versus 36.6 ± 7.9 mm, P < 0.001), a lower frequency of non-compliant balloon (26.0% versus 56.0%, P = 0.002), and a smaller PCB diameter (5.32 ± 0.65 versus 5.66 ± 0.52 mm, P = 0.002) compared with the scoring group. The primary endpoint of technical success was significantly higher in the UltraScore group than in the scoring group (76.0% versus 56.0%, P = 0.035). There were no significant differences in periprocedural complications (4.0% versus 2.0%, P = 0.562), six-month restenosis (4.0% versus 8.0%, P = 0.339), and TLR (2.0% versus 4.0%, P = 0.500) between both groups. The multivariate logistic regression analysis showed that UltraScore use was independently associated with an increase in technical success (odds ratio: 2.58; 95% confidence interval: 1.05-6.36, P = 0.040). CONCLUSION: The use of an UltraScore balloon during PCB angioplasty for femoropopliteal lesions significantly improved technical success compared with conventional scoring balloons. UltraScore use was an independent predictor of technical success, indicating its potential advantages in peripheral intervention procedures.

Fracking compared to conventional balloon angioplasty alone for calcified common femoral artery lesions using intravascular ultrasound analysis: 12-month results.

BACKGROUND: Fracking is a novel technique to crack calcified lesions by hydraulic pressure. This study aimed to compare the performance of fracking and conventional balloon angioplasty without stenting for calcified common femoral artery (CFA) lesions using intravascular ultrasound (IVUS) analysis. METHODS: This retrospective, single-center, comparative observational study included 59 patients (67 limbs) with calcified CFA lesions treated with either fracking (n = 30) or balloon angioplasty (n = 29) between January 2018 and December 2020. The primary endpoint was 1-year primary patency. The secondary endpoints included procedure success, freedom from target lesion revascularization (TLR), procedure-related complications, and freedom from major adverse limb events (MALE). Predictors of restenosis were identified using multivariate Cox proportional hazards analysis. RESULTS: The mean follow-up duration was 403 ± 236 days. The fracking group had significantly higher incidence of 1-year primary patency (89.8% versus 49.2%, P < 0.001), procedure success (96.9% versus 74.3%, P = 0.009), and freedom from TLR (93.5% versus 74.2%, P = 0.038) than the balloon group. The rate of freedom from MALE was significantly higher in the fracking group than in the balloon group (76.9% versus 48.6%, P = 0.033). The groups had no significant difference in procedure-related complications (6.2% versus 5.7%, P = 0.928). A larger postprocedural IVUS-estimated minimum lumen area (MLA) was associated with a lower risk of restenosis (hazard ratio, 0.78; 95% confidence interval, 0.67-0.91; P < 0.001), with a cut-off value of 16.0 mm2 determined using receiver operating characteristics curve analysis. The incidence of 1-year primary patency in patients with a postprocedural MLA ≥16.0 mm2 (n = 37) was significantly higher than that in those with a postprocedural MLA < 16.0 mm2 (n = 30) (87.8% versus 44.6%, P < 0.001). CONCLUSION: This study demonstrated the superior procedural efficacy of fracking compared to balloon angioplasty in treating calcified CFA lesions. The safety outcomes after fracking were comparable to those after balloon angioplasty. Large postprocedural MLA was an independent positive predictor of patency.

Lock and dock: Two-step transvenous retrieval of a fractured femoral sheath with a vascular snare via the right internal jugular vein.

An 86-year-old male with progressive palpitations and dyspnea was referred to our hospital for heart failure treatment. Catheter ablation was performed for atrial flutter as we suspected tachycardia-induced cardiomyopathy as the cause of the patient's heart failure. Due to difficulty securing a peripheral venous route, a 6-Fr sheath was inserted via the right common femoral vein prior to administering general anesthesia. While attempting to insert a mapping catheter, the 6-Fr sheath became lodged and subsequently fractured during removal. Percutaneous transvenous retrieval using an 8-Fr sheath was unsuccessful, and a switch to a right internal jugular vein approach with a 16-Fr sheath was necessary for successful retrieval. The following two-step retrieval ("lock and dock") was then performed: 1) lock: a vascular snare was used to catch the remaining wire crossing into the fractured sheath lumen to prevent the risk of sheath migration to the right ventricle or the pulmonary artery, and 2) dock: the same snare was subsequently used to catch the fractured sheath. The planned catheter ablation was then successfully performed, without any complications. Learning objective: Our case presents, "lock and dock," a novel approach for percutaneous transvenous retrieval that involves two steps: a vascular snare is used to catch the wire and subsequently the fractured sheath. This use of a vascular snare and a large-diameter sheath through the right internal jugular vein effectively reduces the possibility of fractured sheath migration.

Subintimal Tracking and Re-entry Technique for Stent-Jailed Side-Branch Occlusion.

OBJECTIVES: This study aimed to evaluate the clinical effectiveness and outcomes of treatment with the subintimal tracking and re-entry technique for stent-jailed side branch (SB-STAR). SB occlusion is a serious complication of percutaneous coronary intervention (PCI). However, conventional strategies may fail to recanalize the stent-jailed SB. METHODS: We retrospectively analyzed consecutive patients who underwent elective PCI and were treated with SB-STAR at the Sapporo Cardiovascular Clinic in Japan. SB was treated for severe stenosis, reduced thrombolysis in myocardial infarction flow grade, or ischemic signs after main vessel stenting. Technical success during the procedure and clinical and angiographic follow-up findings at 6 months were analyzed. RESULTS: Of the 13,431 PCI procedures performed between January 2016 and June 2021, SB-STAR was performed in 10 patients. The angiographic success rate was 100%. At the 6-month follow-up, no deaths or target-vessel revascularizations had occurred. All patients underwent angiographic follow-up, and 8 of the 10 patients (80%) who underwent SB-STAR had confirmed patency. CONCLUSIONS: SB-STAR can be a bailout strategy to improve the critical situation of stent-jailed SB occlusion. At 6-month follow-up, the SB-STAR had good patency as well as good clinical outcomes.

The "Fracking" technique: a novel approach to crack deep calcified plaque in the common femoral artery with hydraulic pressure.

BACKGROUND: The patency achieved by conventional peripheral interventions for atherosclerotic lesions in the common femoral artery (CFA), called the "no stenting zone", is not superior to that achieved by surgical endarterectomy due to calcified plaque occupying the area. Plaque modification strategies to obtain acute gain in CFA patency provide the better clinical outcomes than standard balloon angioplasty. Atherectomy devices, which focus on the modification of superficial calcifications, contribute to the improvement of clinical outcomes. However, deep calcifications resist vessel expansion such that luminal gain is not easily achieved. MAIN TEXT: We propose a novel calcified plaque modification technique, named the "fracking technique" (FT). The term fracking refers to how a rock is fractured by the high hydraulic pressure. In this technique, deep calcifications are cracked with hydraulic pressure via a balloon indeflator through an 18-gauge needle, which punctures calcifications to achieve greater acute luminal gain. Case 1 involved an 81-year-old male with eccentric calcified plaque in the right CFA. Conventional balloon angioplasty for the lesion yielded a suboptimal minimal lumen area (MLA), which increased from 6.2 to 10.7-mm2 on intravascular ultrasound (IVUS). The FT was implemented to obtain a larger MLA. After the FT was repeated at three locations at up to 8-atm, a greater MLA of 27.1-mm2 was achieved without complications. Case 2 involved a 72-year-old male undergoing hemodialysis due to diabetes mellitus who presented with ischemic pain in his right limbs at rest due to severe stenosis with eccentric calcification in the distal CFA. The MLA on IVUS before and after balloon angioplasty was 10.0-mm2 and 13.1-mm2, respectively, and this result was still suboptimal. The FT was attempted and successfully yielded a greater MLA of 28.9-mm2 without complications. Restenosis has not been detected for 2 years follow-up period. CONCLUSIONS: The FT is an effective option for treating calcified CFA lesions to achieve a larger lumen area. Long-term follow-up studies are necessary.

The "Needle bypass" technique: Percutaneous anatomical bypass with needle rendezvous for patients with peripheral arterial disease that have no other surgical options.

BACKGROUND: The ideal method for recanalization of complex peripheral lesions has not been determined, despite the use of the latest endovascular devices. We describe a novel method for a fully percutaneous anatomical bypass, named the "needle bypass" technique, for treatment of complex vascular lesions with failed previous surgical therapy. MAIN TEXT: A 68-year-old male patient with chronic limb-threatening ischemia presented to our department. He previously had received surgical treatment 10 years prior that included the removal of the right distal common femoral artery and two surgical bypasses, an axillary-femoral bypass and an iliofemoral bypass, because he had repeated infections. He was referred to our center in order to have peripheral interventions. Since the previous conventional bridging/revascularization of the removed common femoral bifurcation had failed, the "needle bypass" technique was then used. With this novel technique, the tips of two percutaneous and bidirectional inserted needles were aligned ("needle rendezvous") for the externalization of a guidewire in a through-and-through manner. Once this was achieved, an endovascular stent graft and an interwoven stent were deployed to cover and connect the lesion. This new technique is a minimally invasive anatomical bypass that directly connects artery to artery without any disturbance of the venous flow, and this technique, as the only option available, was performed successfully in our no-option patient. CONCLUSIONS: The "needle bypass" technique is an effective percutaneous treatment method in patients with no other surgical options.

The "Direct tip injection in occlusive lesions (DIOL)" fashion.

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.

The "needle re-entry" technique for infrainguinal arterial calcified occlusive lesions.

BACKGROUND: Vascular calcification is a predictor of poor clinical outcome during and after endovascular intervention. Guidewire crossing techniques and devices have been developed, but chronic total occlusions (CTOs) with severe calcification often prevent subintimal re-entry. We propose a novel guidewire crossing approach combined needle rendezvous with balloon snare technique, named the "needle re-entry" technique, for treatment of complex occlusive lesions. MAIN TEXT: A 73-year-old female with severe claudication in her right calf with ankle brachial index of 0.62, and a computed tomography angiogram showed a long occlusion with diffuse calcification in superficial femoral artery. She was referred to our department to have peripheral interventions. Since the calcified vascular wall of the lesion prevented the successful re-entry, the "needle re-entry" was performed. First, a retrograde puncture of the SFA, distally to the occlusion, was performed and an 0.018-in. guidewire with a microcatheter was inserted to establish a retrograde fashion. Second, an antegrade 5.0-mm balloon was advanced into a subintimal plane and balloon dilation at 6 atm was maintained. Third, an 18-gauge needle was antegradely inserted from distal thigh to the dilated 5.0-mm balloon. After confirming a balloon rupture by the needle penetration, we continued to insert the needle to meet the retrograde guidewire tip. Then, a retrograde 0.014-in. guidewire was carefully advanced into the needle hole, named the "needle rendezvous" technique. After further guidewire advancement to accomplish a guidewire externalization, the needle was removed. Finally, since the guidewire was passing through the 5.0-mm ruptured balloon, the balloon was withdrawn, and the guidewire was caught with the balloon and successfully advanced into the antegrade subintimal space, named the "balloon snare" technique. After the guidewire was advanced into the antegrade guiding sheath and achieved a guidewire externalization, an endovascular stent graft and an interwoven stent were deployed to cover the lesion. After postballoon dilation, an angiography showed a satisfactory result without complications. No restenosis, reintervention, and limb loss have been observed for one year follow-up period after this technique. CONCLUSIONS: The "needle re-entry" technique is a useful guidewire crossing technique to revascularize femoropopliteal complex CTOs with severe calcification which prevent the achievement of guidewire crossing with the conventional procedures.