The ViaHole Technique: A Novel Approach for Recanalizing Major Side Branch Occluded by Viabahn Stent-Graft

Abstract

Abstract Background: Heparin-bonded endoluminal stent-graft covered with expanded polytetrafluoroethylene (ePTFE) has been utilized to manage arterial rupture. Stent-graft implantation might require crossing a major branch for hemostasis, potentially causing limb ischemia. We propose the ViaHole technique as a novel recanalization method for major branch occlusion. Main text: A 72-year-old male with a history of right popliteal aneurysm treatment involving stent-graft implantation suffered from acute limb ischemia (ALI). Imaging revealed occlusion from the distal superficial femoral artery (SFA) to below-the-knee arteries. During thrombus removal attempts by surgical thrombectomy, an unintentional rupture occurred in the proximal posterior tibial artery (PTA). Surgical bypass was infeasible due to no run-off in below-the-knee arteries. Hemostasis was succeeded by endoluminal stent-grafts implantation from the tibioperoneal trunk to the proximal PTA. However, recurrent ALI occurred three months later. Surgical bypass was again deemed unfeasible due to no distal anastomosis site. After unsuccessful recanalization attempts for bilateral tibial arteries, the decision was made to recanalize the peroneal artery occlusion using the ViaHole technique. This technique involved several steps: 1) advancing retrograde devices into the peroneal artery occlusion, 2) guiding the retrograde guidewire to touch the outer surface of the posterior wall of the ePTFE on the stent-graft at the peroneal arterial ostium, 3) puncturing the stent-graft completely using a 20-gauge needle to touch the retrograde device, 4) manipulating the retrograde guidewire through the needle hole and externalizing it, 5) advancing the retrograde microcatheter over the guidewire and through the hole of the ePTFE into the tibioperoneal trunk, 6) catching the retrograde microcatheter using an antegrade 4-Fr catheter, 7) inserting an antegrade guidewire into the retrograde microcatheter, 8) advancing an antegrade microcatheter into the peroneal artery, 9) dilating the lesion and stent-graft hole using a 3.0-mm noncompliant balloon, 10) ensuring hemostasis by inflating the 3.0-mm balloon to achieve hemostasis at the puncture site. The final angiogram demonstrated sufficient blood flow, resulting in symptom improvement. The patient was discharged on the third postoperative day, and 1-year patency was confirmed. Conclusions: The ViaHole technique may be valuable for revascularizing a major side branch occluded by stent-graft implantation.