Case study: Bilateral iliac recanalisation procedure using Outback catheter

Clinical details
The patient, a middle-aged non-diabetic white male, was referred from the Vascular surgery Outpatient Clinic with chronic bilateral intermittent claudication. Initial efforts to perform a diagnostic angiogram were unsuccessful due to difficulty in retrograde advancement of the catheter and guidewire into the aorta from both femoral approaches using the Seldinger technique. Hence, a diagnosis of bilateral iliacocclusion was made. The case was discussed at the Vascular Multidisciplinary Meeting and it was collectively decided to go ahead with bilateral iliac recanalisation procedure using the Outback Re-Entry LTD Catheter.

Procedure
Initially, a diagnostic angiogram of the lower extremities was performed using the brachial puncture and placement of a pigtail catheter in the lower abdominal aorta. The exact extent of the bilateral iliac occlusion was ascertained. After gaining access into the femoral arteries under fluoroscopic control, 6F short sheaths (Cook) were put in place. A subintimal track extending from the occluded left common iliac artery up to the lower abdominal aorta just proximal to the iliac bifurcation was carefully created in a retrograde fashion under fluoroscopic guidance using a 4F multipurpose catheter (Cordis) and 0.035 guidewire (Terumo). The 0.035" guidewire was then exchanged for a 0.014" guidewire (Cordis).

The Outback Re-Entry LTD Catheter (Cordis) was prepared by saline flush and was exchanged for the multipurpose catheter by advancing over the 0.014" guidewire. The tip of the catheter was advanced into the subintimal track and placed adjacent the true lumen of the lower abdominal aorta just proximal to the aortic bifurcation. The orientation of the catheter tip towards the aortic lumen was confirmed by performing check angiograms through the pigtail catheter at two oblique projections separated at 90-degree angle. The 0.014" guidewire was withdrawn and the aortic intima was punctured with the needle tip of the Outback Re-Entry LTD Catheter under fluoroscopic control. The 0.014" guidewire was then advanced through the needle tip into the aortic true lumen. Having gained access into the true lumen, the catheter was withdrawn and exchanged for a Amiia balloon (Cordis) and the intimal puncture wound was widened.

The 0.014" guidewire was then exchanged for an Amplatz Stiff guidewire (Boston Scientific) over a multipurpose catheter. The entire process of subintimal recanalisation process was repeated on the right side. Having thus placed Stiff guidewires in the iliac arteries bilaterally, the short sheaths were exchanged for long 6F Destination sheaths (Terumo) and the tip of the sheaths was positioned in the lower abdominal aorta. Appropriate measurements were obtained on both sides for the purpose of stent placement. Eight millimetres x 80mm and 8mm x 60mm sized Wallstents (Boston Scientific) were successfully deployed on the right side and the left, respectively, and post-dilated with 8mm OptaPro balloon (Cordis). On completion an angiogram revealed satisfactory revascularisation of both iliac arteries. The patient was put on anticoagulants and anti-platelet agents in the follow-up period. Follow-up doppler evaluation of the iliac arteries at three weeks post-procedure revealed patent lumina with satisfactory flow bilaterally.

Discussion
Outback Re-Entry LTD Catheter enables recanalisation of chronic occlusion of iliac arteries to be performed accurately and safely. While the need for iliac by-pass surgery is avoided, at least in the short-term, long-term patency of the stents needs to be evaluated.