Efficacy of Navigating Through the Intraplaque Route using AnteOwl WR Intravascular Ultrasound in Femoropopliteal Chronic Total Occlusion

Abstract BackgroundThere is no consensus on the optimal guidewire passage route for femoropopliteal (FP) chronic total occlusion (CTO). If intraplaque wiring can be performed, a stent-less strategy using a drug-coated balloon (DCB) can be realized even with FP CTO, and there is a high possibility that good expansion can be obtained even when stent deployment is performed. AnteOwl WR (AnteOwl) is a novel intravascular ultrasound (IVUS) device useful for navigating the second guidewire into the intraplaque route under IVUS observation from the subintimal space. Here, we describe representative cases of FP CTO in which CTO-specific IVUS was extremely useful.Case presentationCase 1 was a 79-year-old man undergoing hemodialysis who presented with claudication of the left lower limb. Control angiography showed total occlusion of the left superficial femoral artery (SFA). We performed antegrade wiring, but the guidewire was advanced into the subintimal space. We advanced AnteOwl into CTO. Using the AnteOwl IVUS transducer and IVUS-wire bias, we found that the IVUS-wire is at the top and the transducer is at the bottom, and based on this information, a plaque to aim exists on the right side of the IVUS catheter at right anterior oblique of 30°. By aiming the wiring in that direction, we succeeded in traversing the center of the plaque and finally succeeded in obtaining good expansion using the DCB. Case 2 was of an 76-year-old woman with ulceration and gangrene of the left foot. Control angiography showed total occlusion from the SFA to the popliteal artery (Pop A). When AnteOwl was placed on the wire and advanced to the Pop A, the subintimal space in the middle of the SFA could be visualized. We employed an IVUS-guided parallel wire technique and succeeded in passing through all intraplaque routes. Although the CTO was long, we could easily advance through the intraplaque route by reflecting the information obtained from AnteOwl in angiography.ConclusionsAnteOwl is an effective IVUS technique for FP CTO and facilitates a complex IVUS-guided procedure.