Anterograde and Retrograde Approach With Through-and-Through Wiring Technique to Treat a Ruptured and Extremely Tortuous Giant Popoliteal Artery Aneurism

Introduction

Popliteal artery aneurism (PAA) is a rare clinical condition affecting less than 1% of population. ¹ Its clinical significance lies on potential complications related with acute limb ischemia secondary to thromboembolism, rupture and deep vein thrombosis. ² Rupturing of PAA is rather infrequent. In largest reported series, around 2-5% of PAA that have been surgically managed were found to be ruptured within the surgery.^3,4 Management has traditionally been surgically, however, in recent years considerable development of endovascular techniques and materials has added an interesting and less invasive treatment approach, particularly in high risk patients.^3,4

At a technical level, endovascular treatment consists in exclusion of the aneurism with a stent graft. Technical challenges in these situations are seen when a PAA is too large, resulting in bending and kinking of adjacent artery segments, or in an acute setting such as rupturing. In these scenarios, inability to cross a wire through the distal portion of the aneurism or getting enough support to advance angioplasty materials (balloons, stents, grafts, etc) may be a common cause of endovascular failure. Through-and-through wire technique may help gaining support, straighten bends and kinks, and therefore facilitate the procedure.

We present a highly technical challenging endovascular case of a giant, highly tortuous and ruptured PPA in an elderly high risk surgical patient presenting with acute limb ischemia.

Materials and Methods

Case Presentation

An 86-year-old male patient is admitted in the Intensive Care Unit (ICU) for acute lower right limb ischemia with rest pain, functional impotence and augmentation of the popliteal fossa. No neurological deficit was observed of the foot. Bed-side ultrasound showed a large patent aneurism of proximal right popliteal artery, and diminished flow velocities in anterior and posterior tibial arteries. Angio-CT was performed for further anatomical evaluation and showed a heavily calcified superficial femoral artery with a 180° bend in the distal portion, followed by a large PAA (63 × 61 mm) of P1 segment of popliteal artery and an extent hematoma (142 × 112 × 104 mm) (Figure 1). P3 was patent, although in a late phase. Endovascular approach was elected due to high morbidity.

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Figure 1.

CT showing heavily calcified femoro-popliteal segment, with a 180° bend between superficial femoral artery and P1 segment and a large popliteal artery aneurism.

Results

Under general anesthesia, anterograde puncture of the superficial femoral artery at the groin level was performed via echo-guidance in a segment with no calcium. Pre-close with 2 Proglides® (Abbot Vascular) was performed, and a 10 cm 11F sheath (Terumo®) was placed. Angiogram showed a heavily calcified superficial femoral artery with conserved flow, P1 of popliteal artery calcified with a 180° bend, and P2 segment ruptured with extravasation of contrast into a pseudo-cavity. P3 and tibio-peroneal trunk were heavily calcified, and all contrast dye was retained in the cavity (Figure 2). An anterograde approach was first intended by advancing a 0.035″ hydrophilic coated wire (Glidewire®, Terumo) into the ruptured aneurism and through P3 of the popliteal artery. Despite various attempts with support of a hydrophilic vertebral 5F catheter, wire could not be passed through P3 given the large size of the aneurism and the extreme tortuosity of the artery (Figure 3). A retrograde approach was performed percutaneously via tibio-peroneal trunk under fluoroscopic guidance by puncturing the anterolateral side of the leg with a 5F micropuncture set (Access Set®, Cook Medical). Then, a stiff 0.035″ Glidewire® was successfully advanced into the aneurism for anatomical guidance of the distal portion of the popliteal artery. Anterograde advancement of the hydrophilic wire into P3 was finally achieved, following by advancement of a vertebral catheter distally in order to wire it through the retrograde approach (Figure 4). Finally, the retrograde wire was snared and retrieved proximally through the 11F sheath to obtain a through-and-though wire technique (Figure 5). Tightening of both ends of the wire was done next, and consequently the bends of the artery were straightened considerably. This allowed advancement of angioplasty materials.

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Figure 2.

Initial angiogram. Contrast retained in the cavity with poor run off in the P3 segment.

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Figure 3.

Anterograde approach to advance wire through P3 segment with support of a 5F hydrophilic vertebral wire with no success.

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Figure 4.

Wiring of the vertebral catheter from the retrograde access.

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Figure 5.

Through-and-through wiring techniques after tightening both ends of the wire. Note the proximal bend in P1 straighten considerably.

Aggressive pre-dilation was performed specially in calcified and bended segments with 7 × 80 mm and 8 × 80 mm balloons (Admiral Xtreme®), followed by angioplasty with a 8-mm-diameter by 25 cm long GORE VIABAHN® endoprosthesis. During control angiogram, a slight endoleak into the distal portion of the graft was seen in a late phase, therefore a successive angioplasty with another 10-mm-diameter by 5 cm-long GORE VIABAHN® endoprosthesis was performed distally with good contrast run-off and angiographic result (Figure 6).

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Figure 6.

Final result with digital subtraction. Popliteal aneurism totally excluded with good run-off to distal P3 and no residual leak after treatment with 2 Gore-Viabahn grafts.

Hemostasis of retrograde puncture site was obtained by prolonged inflation of a 4 mm balloon (Ademiral Xtreme®) with no residual blood loss and anterograde puncture site with double Proglide® technique. After the procedure, the patient was pain free of the foot and the popliteal fossa, and so sings of reperfusion injury were noted.

At 1-month follow-up, angio-CT showed total exclusion of the ruptured aneurism, with patent popliteal artery run-off and no residual leak (Figure 7). The patient was able to walk, and was anticoagulated with a low dose Rivaroxaban 2.5 mg bid plus aspirin as secondary prevention.

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Figure 7.

Angio-MSCT at 1 month follow-up. Total exclusion of the ruptured aneurism, with patent popliteal artery and no residual leak. Note a slight kinking of the stent graft in the first and second bends.

Discussion

Rupture of a PAA is a rare complication of a rare disease.^3,4 Usually, patients with ruptured PAA tend to be older than those with non-ruptured and diameters are quite larger. ⁴ Traditionally, management of ruptured PAAs has been surgical, however clinical profile of these patients are of high morbidity and advanced age. This leaves a proportion of patients of high surgical risk candidates for endovascular treatment. Endovascular treatment consists in exclusion of the aneurism with a stent graft. From a technical point of view, passing the guide wire through the aneurism and into the distal vessel usually does not result in a challenge. However, when the aneurism is quite large like in our case, it may alter the anatomic normal trajectory of the artery resulting in bending and kinking of adjacent portions, thus resulting technically difficult to navigate the guidewire through the aneurism. In addition to the latter, the presence of a large thrombus burden occupying a large part of the aneurism surrounding entry area near P3 resulted in further challenge in advancing the wire anterogradely where the vessel recovered diameter (Figure 1). Our case was planned considering this anatomic difficulty with help of the angio-CT, and the retrograde approach left as bailout. After several intents to wire P3 segment through the ruptured aneurism from the superficial femoral artery, the retrograde approach was indispensable to obtain a “through-and-though” wire technique. After achieving this, tightening of the 2 ends of the wire was a key maneuver which allowed straightening of the bends in the proximal and distal portion of the aneurism. Consequently, sufficient support was gained so balloons and stent grafts would pass through these curves. As far as we know, this is a first time a double access technique has been described in the literature for endovascular managing of PAAs. We consider that without this technique, successful endovascular treatment of this ruptured giant, highly tortuous PPA in this patient would not have been possible.

Additionally, femoropopliteal artery stent thrombosis occurs in approximately 4.3% of patients undergoing stent procedures. ⁵ Thus, special attention should be taken into consideration at follow-up. Angio-CT at 1-month follow-up showed a patent grafted segment of the popliteal artery, and a slight kinking of the stent within de first and second bend (Figure 7). This last could be a predictor of stent thrombosis at follow-up. In addition to the kinking, the loss of collaterals and edge restenosis are known factors of Viabhan stent graft restenosis. ⁶ Hence, due to potential increased risk of stent thrombosis, anticoagulation with low-dose Rivaroxaban 2.5 mg bid and aspirin was chosen according to the Voyager-PAD regimen. ⁷