Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3803_Библиотеки_им_академика_М_И_Перельмана

The RIM catheter can be dropped to engage the contralateral common iliac artery origin. Imaging can be achieved by either (1) contrast injection into the contralateral common iliac artery to image the CFA bifurcation and capture the mid and distal supercial femoral artery segments or (2) using the CFA bifurcation image from the aortography and plan for selective injection of CFA. For the latter, a supportive hydrophilic 0.035-in guidewire (Advantage Glidewire, Somerset, NJ) can be advanced through the RIM catheter into the distal SFA, the RIM catheter is with­drawn and exchanged, and a straight tip end-hole 0.035-in catheter (CXI, Bloomington, IN) can then be advanced. Advancement of the RIM catheter into the distal SFA is not advised. The curved catheter tip is positioned against the vessel wall, and contrast injection can cause dissection or contrast staining. Selective cannulation of the SFA allows for FP and below-the-knee (BTK) angiography. It is important to note that if the ostial or proximal SFA is occluded, selective angiography of the CFA with lling of the profunda femoris can opacify distal reconstitution to evaluate distal FP, BTK, and distal foot perfusion. In patients with critical limb ischemia, visualization of pedal vessels is especially necessary. In claudicants, imaging up to the ankle vessels is highly recommended. It is best practice to evaluate foot perfusion in all cases if feasible. Selective DSA of distal FP or BTK angiography is preferred over runoffs in the absence of proximal or ostial SFA occlusion.

sufcient visualization of the primary lesion, delineation of distal and BTK vessels, account for surrounding atherosclerosis, and facilitation of the hybrid approach. Beginning with a 6- or 7-Fr vascular access sheath placed in the contralateral com­mon femoral artery is frequently used to treat FP-CTO lesions. Of note, the tip of the 45-cm crossover sheath should be placed near the SFA-popliteal artery bifurcation as this will provide adequate support for additional guidewires and catheters.

position to conrm if the needle is in line with the SFA.Once proper needle position is conrmed, the distal SFA can be punctured. A 0.018-in guidewire (V-18 Control, Boston Scientic, Natick, MA, USA) can be inserted through the needle followed by a 4- or 6-Fr, 10-cm sheath (Terumo) or support catheter. To deliver CCDs, a sheath may need to be inserted through the retrograde SFA puncture. Externalization and preferably antegrade delivery of balloons and stents complete FP-CTO recanaliza­tion. A retrograde guidewire can be advanced to engage the distal cap to serve as a distal cap marker when it is ambiguous or suboptimally visualized on angiographic imaging. This can assist with antegrade crossing. Pedal artery access is included in the section dedicated to below-the-knee CTO.

“Tunneling” refers to passing a retrograde or antegrade guidewire from a respective retrograde or antegrade catheter into a receiving catheter on the contralateral side [29]. The re-back technique involves the use of a needle-based reentry device into a retro­grade balloon [30]. Ination of two balloon catheters over antegrade and retrograde guidewires in order to merge the subintimal places is referred to as the double-balloon technique. This can facilitate true lumen entry in either the antegrade or the retrograde direction [23]. Finally, controlled dissection reentry can be achieved through special­ized reentry devices. Figure14.7 highlights guidewire selection for FP-CTO crossing. Tables 14.1 and 14.2 depict preferred guidewires and crossing devices.