A 68-year-old male patient with a history of right common femoral artery (CFA), axillary-femoral bypass, and ilio-femoral bypass transection due to recurrent methicillin resistant staphylococcus aureus (MRSA) infection after Miles’ operation and lymphadenectomy for anal cancer 10 years ago was suffered from ischemic right foot pain at rest. The ankle brachial index was 0.59 in the right leg. The patient was referred to our hospital to undergo EVT by vascular surgeon due to the high risk of complications from surgical procedures. Computed tomography angiogram (CTA) showed that there were some skin defects, anastomosis sites, and no arteries from distal CFA to proximal superficial femoral artery (SFA) in his right leg due to frequent surgical treatments. Contrast effect was found from stenotic middle SFA to normal distal vessel.
The lesion was extremely complicated, and bi-directional approach was performed from the beginning. 7-Fr guiding sheath (Destination®︎, Terumo Co., Japan) as antegrade crossover approach and 6-Fr guiding sheath (Parent Cross®︎, Medikit Co. Ltd., Japan) as retrograde approach were inserted via left CFA and right popliteal artery, respectively. Angiographical image showed the same overview of lesion as CTA (Fig. 1A). Any hard guidewire including tail of 0.035-in. wire supported with 4-Fr catheter (Tempo®︎, Cardinal Health Inc., USA) were not able to advance into the lesion and outside the vessel due to the solid tissue hardened from the repeated infections and surgical procedures. Since it was too difficult to treat with conventional intervention, “Needle bypass” technique as a novel percutaneous anatomical bypass was implemented. After the administration of local anesthesia to the puncture spots, 18-gauge needle (Terumo Co., Japan) punctured retrogradely from the proximal thigh into the body below the proximal true lumen (Fig. 1B, 1C) and the other 18-gauge needle punctured antegradely from the right groin via right CFA in front of the proximal CTO orifice, confirming the tip of the needle inside CFA by the sign of blood return, and continued inserting to meet the tip of retrograde needle. 0.014-in. guidewire was manipulated carefully to advance into the hole of the other needle to attempt the guidewire externalization from needle to needle, named the “Needle rendezvous” technique (Fig.1D).
A new 6-Fr Parent Cross®︎ sheath was inserted antegradely over the pull-through guidewire between the puncture sites (Fig. 2A). 4.0x20-mm semi-compliant balloon (Sterling®︎, Boston Scientific Co., USA) dilated the tissue in front of antegrade guiding sheath to create a space, and 18-gauge needle punctured antegradely from the proximal thigh through the space, which was formed by previous balloon dilatation, to reach the distal true lumen as 4-Fr retrograde catheter was targeted. (Fig. 2B). 0.014-in. guidewire through the needle was advanced antegradely into the retrograde catheter to perform the guidewire externalization. 4-Fr catheter was inserted retrogradely over the pull-through guidewire into the space formed with previous ballooning. 0.035-in. guidewire and 4-Fr catheter as retrograde system were manipulated gently to advance through the 6-Fr antegrade guiding sheath (Fig. 2C) to right CFA. Antegrade 6-Fr guiding sheath was pulled out into right CFA as proximal true lumen. After bi-directional systems were separated from each other within right CFA lumen, 0.014-in. guidewire via 4-Fr retrograde catheter were advanced through the space and into 7-Fr antegrade guiding sheath inserted via left CFA as crossover approach to accomplish the true guidewire externalization between bi-directional guiding sheathes (Fig. 2D).
In order to treat the complex lesions including extravascular route, “Pave-and-Crack” technique which facilitates the safe introduction and effective scaffolding of stent-grafts through the lesion access followed by an aggressive balloon dilatation was intentionally performed (R.J. Hinchliffe, et al. 2007; M. Dias-Neto, et al. 2018). The lesion was aggressively dilated with a 7.0x40-mm non-compliant balloon (SHIDEN HP, Kaneka Co., Japan) and fully covered with a 7.0x250-mm stent graft (Viabahn®︎, W. L. Gore & Associated, Inc., USA). In this case, it was mandatory to implant interwoven stent (Supera®︎, Abbott Vascular, USA) which provides higher radial force to resist recoil and extrinsic compression from the solid tissue in the extravascular site and hip joint motion. After 6.5x150-mm interwoven stent implantation and post-balloon dilation with 7.0-mm non-compliant balloon with highest pressure, angiogram and intravascular ultrasound finally demonstrated the great success of “needle bypass” technique to perform percutaneous anatomical bypass without any complications (Fig. 3A, B, C). His symptom and physiological examinations were completely improved after the procedure, and there have been no events of patency loss, reintervention, and stent thrombosis a year after the treatment (Fig. 3D).