26 CASE REPORT MAY 2016 Critical Limb Ischemia: Revascularization Techniques to Optimize Endovascular Therapy in Complex Cases Using the JETSTREAM Atherectomy System Figure 1. Diagnostic angiogram showing flow in the superficial femoral artery (A), popliteal (B), and tibial circulation (C), and revealing a chronic total occlusion (CTO) of the popliteal, along with occlusive tibial disease. Pictured above is the latest-generation JETSTREAM atherectomy system. The device has been successfully iterated seven times since its launch in 2008. Fadi Saab, MD, FACC, FASE, FSCAI, Cardiovascular Medicine-Interventional Cardiology, Associate Director of Cardiovascular & Endovascular Laboratories, Associate Director of Pulmonary Embolism andVenousThrombosis Services, Clinical Assistant Professor-Michigan State University, School of Medicine, Figure 2. Extravascular ultrasound (EVUS) showing the .035-inch support catheter Metro Health Hospital,Wyoming, Michigan traveling through the chronic total occlusion (CTO) in the popliteal artery. may not be adequate candidates for surgi- valve replacement five years prior.There cal bypass. Endovascular therapy has been were no other significant co-morbidities. fueled by continuous innovation in tech- His clinical exam revealed a cold right Introduction niques and devices.6 The JETSTREAM™ lower extremity with no palpable pulses. The prevalence of peripheral vascu- Atherectomy System (Boston Scientific) The clinical workup included a 2-dimen- lar disease (PVD) has been increasing is a rotational device, featuring front-cut- sional echo with an ankle-brachial index worldwide.The number of patients suf- ting, expandable blades. JETSTREAM (ABI). Echo revealed his left ventricular fering from PVD is expected to increase is also the only atherectomy system with function to be preserved, with no val- by 15% in western countries and 30% in active aspiration.The rotational aspect of vular or wall motion abnormalities. The developing countries.1 This increase is a the device allows for plaque modification right-side ABI was significantly abnormal reflection of other co-morbidities driv- and debulking.The device is engineered at 0.4.The patient did not have any his- ing the rise in numbers. Patients with to predictably treat multiple morpholo- tory of deep venous thrombosis or pul- PVD suffer from higher morbidity and gies, such as calcium, plaque or thrombus, monary embolism, nor was there any his- mortality.2,3 Multiple modalities exist to commonly found in total occlusions.We tory of arterial thrombosis. A diagnostic evaluate and treat patients with PVD. will present a case that demonstrates the angiogram revealed evidence of multi- Endovascular revascularization of pa- versatility of the device in treating a com- level disease involving the right lower tients with PVD is becoming a front-line plex clinical and anatomical situation in a extremity.The lesion appeared to extend strategy adopted by several disciplines, patient with critical limb ischemia (CLI). from the distal popliteal artery into the including vascular surgery, radiology, and posterior tibial and tibio-peroneal trunks. cardiology. Bypass surgery is an excel- Case presentation The patient had an anomalous high take- Fadi Saab, MD, FACC, FASE, FSCAI lent procedure in appropriately selected A 54-year-old male originally present- off of the right posterior tibial (Figure 1). patients.4,5 However, many PVD patients ed with complaints of life-limiting clau- dication, placing him at Rutherford class Clinical course The physician was compensated by Boston Scientific for his time associated with III.The patient’s past medical history was Due to the complex nature of this oc- this article. significant for hypertension and diabetes. clusion, therapy options included medi- He underwent a bio-prosthetic aortic cal therapy, single-vessel tibial bypass, MAY 2016 CASE REPORT 27 or endovascular therapy. The lesion case required multi-vessel, multi-level burden extending from the peroneal to involved the trifurcation of all tibial intervention, and antegrade access af- the popliteal artery (Figure 4). EVUS im- vessels where the distal posterior tibial forded the operator superior pushability, ages provided similar information. The artery was the only runoff to the foot. trackability,and torquability.We use ul- hypo-echogenic appearance suggested After discussing the options with our trasound (US) guidance in gaining access soft plaque.The JETSTREAM System patient, the decision was made to at- to any vascular conduit. We started with features active aspiration, making it well- tempt medical therapy. The patient was a 5 French Pinnacle Precision sheath suited for the thrombotic-component of placed on antiplatelet therapy with as- (Terumo) and after crossing, upsized to a this lesion. Its rotational blades also pro- pirin. Aggressive lipid-lowering therapy 7 French Destination Pinnacle 45-centi- vide plaque modification and debulking, was also initiated. The patient was not meter sheath (Terumo). making JETSTREAM an ideal solution able to tolerate cilostazol. He contin- for this type of lesion morphology. ued with a self-administered walking CTO crossing. The use of ultrasound program. In addition, we placed the pa- (US) in gaining access to any vascular bed Alternative access. The nature of tient on anticoagulation with warfarin has been shown to be safe and effective. the occlusion in this case highlights the in an attempt to treat what we felt was In addition, it is our experience that extra necessity of alternative access. The le- a thrombotic component on top of the vascular US (EVUS) can also guide CTO sion extended from the popliteal into atherosclerotic disease. Despite treating crossing and therapy delivery. In this case, the posterior tibial/tibio-peroneal trunk/ the patient for 3 months with the above- a .035-inch Navicross catheter (Terumo) peroneal arteries.The angiogram showed mentioned regimen, the patient’s symp- was used to advance through the CTO in a flush occlusion of the posterior tibial toms continued to worsen. The patient a rotational fashion. EVUS allowed us to with reconstitution. Retrograde posterior started complaining of intermittent rest guide the catheter and navigate the CTO tibial US-guided access was the only op- pain, placing him at Rutherford class IV. (Figure 2).We were successful in crossing tion to gain access into the distal patent At this point, we decided to proceed the CTO in the popliteal and peroneal portion (Figure 5).We placed a low-pro- with endovascular therapy in an effort arteries. Once crossing to the distal pero- file Cook tibiopedal sheath (2.9 French) to preserve tibial vessels. neal was confirmed (Figure 3), we started (Cook Medical). Using an .018-inch preparing for therapy. CXI support catheter (Cook Medical), Revascularization steps we advanced an .014-inch Glidewire Access. For any intervention requir- Lesion assessment. There are mul- Advantage wire (Terumo). Crossing into ing the crossing of a chronic total occlu- tiple modalities beyond angiography the true lumen of the popliteal artery in Figure 3. Selective angiography sion (CTO) or treatment of tibial vessels, that permit the operator to evaluate the a retrograde fashion was relatively simple. of the distal peroneal artery after it is our opinion that operators should nature of the atherosclerotic disease. In Using a 7 mm snare, we were able to crossing the occlusion. strongly consider antegrade access. This this case, we utilized EVUS and intra- trap the Glidewire Advantage wire and vascular US (IVUS). The IVUS catheter reverse access (Figure 6). After reversing (Volcano Corporation) was advanced to access, the wire in the posterior tibial ar- the distal peroneal artery. An automated tery was now flossed through the sheath. pullback is preferred to ensure that no The posterior tibial sheath acted as an segments within the vessel are missed. embolic protection system.The peroneal The IVUS image revealed evidence artery CTO was crossed in an antegrade of significant hypo-echogenic plaque fashion and the wire was placed in the Figure 4. IVUS assessment of the popliteal artery, showing significant hypo- echogenic plaque burden. Figure 5. Ultrasound-guided access of the right posterior tibial artery. Note the wire inside the posterior tibial (arrow). Figure 6. Snare system used to capture the retrograde posterior tibial wire (arrow). 28 CASE REPORT MAY 2016 Figure 7. JETSTREAM activation in the popliteal artery under ultrasound and fluoroscopy. Figure 8. JETSTREAM 1.85 mm tibial device activated in the peroneal (Panel A) and posterior tibial arteries (Panel B). distal peroneal artery. An embolic pro- to listen to the pitch of the device.A tection device was deployed in the dis- depressed pitch suggests that the device tal peroneal artery. In an effort to protect rotation has slowed down, and the opera- the distal posterior tibial, we accessed the tor should then carefully pull the device posterior tibial and crossed the occlusion back and re-advance.The operator must after performing atherectomy of the pop- not allow the aspirational capabilities liteal artery. In addition, we did not want of the device to be overwhelmed. After to use the larger JETSTREAM device successful atherectomy “blades-down,” in the popliteal while there was another a “blades-up” run was then performed wire present. with the JETSTREAM device (Figure 7). During the second stage of atherectomy, Atherectomy with JETSTREAM. the peroneal and posterior tibial arteries Atherectomy was performed in two stag- required further therapy. For this stage, we es. During the first stage,we had wire obtained posterior tibial access, crossed access from the popliteal to the peroneal the posterior tibial CTO, and snared the artery. Before crossing from the posterior posterior tibial wire. We proceeded with tibial, we wanted to treat the popliteal/ the use of a 1.85 mm JETSTREAM de- peroneal segment. A 2.4 mm/3.4 mm vice.The tibial device has the rotational JETSTREAM atherectomy device was capabilities without the “blades-up” fea- advanced into the popliteal and acti- ture, and also features active aspiration, vated.The device must be activated with like the larger JETSTREAM devices. the blades down.