Direct graft puncture with use of a crossed catheter technique for thrombolysis of peripheral bypass grafts

Direct puncture versus contralateral femoral artery approach for catheter-directed thrombolysis of occluded infra-inguinal arterial bypass grafts

AIM

To compare the safety, effectiveness, and clinical outcome of percutaneous direct puncture approach versus contralateral femoral native vessel approach for catheter-directed thrombolysis of occluded infra-inguinal bypass grafts.

MATERIALS AND METHODS

A retrospective analysis was performed comprising a cohort of patients who underwent catheter-directed thrombolysis procedures of occluded infra-inguinal bypass grafts between January 2013 and January 2022, with a follow-up period until June 2022. This included 55 procedures via the native vessel approach and 18 procedures via the direct puncture approach. Primary outcomes were technical success and procedural safety; secondary outcomes included re-intervention rate, limb salvage, and mortality as assessed by log-rank testing and Kaplan-Meier curves.

RESULTS

There were no differences between the two groups with regard to patient demographics, except for the number of previous vascular procedures (n=6.83 ± 3.07 direct approach versus n=4.96 ± 2.79 native vessel approach, p=0.025). Thrombolysis was comparably successful in both groups (n=13/18; 72% direct approach versus n=42/55; 76%, p=0.723). There were no differences in the duration of thrombolysis administration. The rate of adverse events was slightly lower in the direct approach group, but without significance (p=0.092). There were no adverse events related to the puncture site in the direct approach group. No differences were found between the time-to-event values for re-occlusion, re-intervention, amputation, or mortality respectively (p=0.662; p=0.520; p=0.816; p=0.462).

CONCLUSION

The direct puncture approach seems to be a safe and efficient approach for catheter-directed thrombolysis procedures in infra-inguinal occluded bypass grafts, with clinical outcomes comparable to the native vessel approach.

Successful case of direct puncture of a prosthetic bypass graft in endovascular treatment for long superficial artery chronic total occlusion: a case report

Background

The access site for endovascular therapy (EVT) is often limited because of multi-vascular diseases. Prior lower limb bypass can potentially limit the availability of common femoral artery access when EVT is required.

Case summary

An 88-year-old woman who presented with non-healing ulceration in the dorsalis pedis of the left foot despite treatment for several months was admitted to our hospital. She had undergone axillo-bilateral femoral bypass surgery for right critical limb ischaemia 3 years previously. Ultrasound and contrast computed tomography demonstrated bypass graft occlusion, left superficial femoral artery (SFA)-popliteal artery long chronic total occlusion from the origin with severe calcification and severe stenosis in the bilateral common femoral artery close to the anastomotic site. EVT for the left SFA occlusion was necessary to save the left foot, but access sites for EVT were limited. We decided to puncture an occluded axillo-femoral prosthetic bypass graft. It is difficult to cross the wire with only an antegrade approach. Therefore, it was necessary to use a bi-directional approach with dorsalis pedis artery puncture and the Rendez-vous technique. Finally, angiogram demonstrated improved blood flow to the wound site, and haemostasis at the puncture site could be achieved by manual compression. The ulceration healed within a month.

Discussion

Direct puncture of a prosthetic bypass graft and additional techniques resulted in complete revascularization. Thus, direct puncture of a bypass graft could be a useful EVT strategy for patients with complex and extremely long chronic total occlusion.

Direct puncture of the prosthetic bypass graft in the treatment of critical limb ischemia patient undergoing prior axillo-femoral bypass

A 76-year-old man presented with a non-healing ischemic ulceration of the left foot. He had undergone left axillo-femoral bypass surgery 4 years previously. Diagnostic angiography showed total occlusion from the left common iliac to the common femoral artery and the anterior and posterior tibial artery as well as severe stenosis of the superficial femoral and peroneal artery. Because there were no other access sites except for the axillo-femoral bypass graft, we performed endovascular therapy (EVT) by direct puncture of this bypass graft. Here, we have described the utility of direct puncture of axillo-femoral prosthetic bypass graft for EVT of the infrainguinal arteries.