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Successful Below-the-Knee Intervention by Reverse CART Technique
- Operator: Seung-Whan Lee, MD
Case Presentation
This 71-year old gentleman was admitted to our hospital for the treatment of the gangrenous wound at right great toe which occurred spontaneously 4 weeks ago. He had medical history of insulin-dependent diabetes, hypertension and hypothyroidism. Even, he had been on peritoneal dialysis for DM end-stage renal disease. The right ankle-brachial index value was severely dropped to 0.48 and the lower extremity CT angiography revealed diffuse stenosis with severe calcification along the right anterior tibial artery (ATA).
Baseline Peripheral Angiography
The right SFA was patent without significant stenosis ( Movie 1). Beyond the patent short segment of the proximal popliteal artery and the TP trunk, ATA was totally occluded. Meanwhile posterior tibial and peroneal arteries were patent. ( Movie 2, Movie 3, Movie 4)
Procedure
A 6Fr. sheath was inserted into the right femoral artery for ipsilateral antegrade approach. After angiography, 6Fr. sheath was exchanged into the 5Fr. Ansel guiding sheath. At the first time, we planned to cross the ATA from the retrograde direction via PTA and plantar loop. A Regalia XS 1.0/0.014 inch-300cm peripheral-guidewire was successfully cross the lesion and externalized through the plantar loop (Figure 1, Figure 2). However, balloon or even micro-catheter was failed to pass the proximal ATA, we decided to cross ATA by antegrade subintimal tracking. With the support of Finecross 1.8Fr microcatheter, the Regalia XS 1.0/0.014 inch-300cm peripheral-guidewire successfully passed the ATA and at the point of distal ATA, we made a small loop for strong push and then advanced wire to the true lumen ( Movie 5). After then, we performed the sequential balloon dilation using SLEEK 2.5x150 and Nanocross 3.0x40, several times (Figure 3, Figure 4). Final angiogram showed a successful result and good blood supply to the right foot ( Movie 6, Movie 7, Movie 8).
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