The "ViaHole" technique for recanalization of a major side branch occluded by a Viabahn stent-graft

Abstract

Abstract Background: Heparin-bonded endoluminal stent grafts covered with expanded polytetrafluoroethylene (ePTFE) are used for iatrogenic arterial injuries. Where the stent-graft is implanted across a major side branch for hemostasis, the branch can become occluded. We propose the ViaHole technique as a novel recanalization method for major side branches covered by a stent-graft. Case presentation: A 72-year-old male with a right popliteal aneurysm was treated using an 8.0 mm × 250 mm stent-graft from the distal superficial femoral artery (SFA) to the popliteal artery. He later presented with acute limb ischemia (ALI), and during treatment, perforation occurred and was repaired using 5.0 × 50 mm and 100 mm stentgrafts from the tibio-peroneal trunk across the peroneal artery (PA) to the posterior tibial artery (PTA). Unfortunately, ALI reoccurred 3-months later, and the initial angiography showed thrombotic occlusion from the distal SFA to the below-the-knee arteries. After successful thrombo-aspiration of the above-the-knee arteries, revascularization of the tibial arteries failed because of a massive thrombus. We attempted to recanalize the PA, whose orifice had been covered by stent-graft placement. First, we advanced a 0.014-inch guidewire with a microcatheter from the distal PTA through the communicating branch to the ostium of the PA. Second, a 20-gauge needle was used to puncture the proximal lower thigh, through the stent-graft to the tip of the retrograde guidewire in the PA orifice. Third, after the needle touched the guidewire tip, the guidewire was advanced out of the body through the hole of the needle to externalize the guidewire. Fourth, the retrograde microcatheter was forcibly advanced over the externalized guidewire across the ePTFE into PTA. Fifth, the antegrade guidewire was passed through the retrograde microcatheter, and the antegrade microcatheter was advanced into the PA through the hole of the stent-graft. After the antegrade guidewire crossed the lesion, a 3.0 mm semi-compliant balloon dilated the lesion and the stent-graft hole. Finally, the angiogram showed sufficient blood flow. A 6-month computed tomography angiogram showed no restenosis of the treated lesion. Conclusions: The ViaHole technique is an effective recanalization procedure for major branches occluded by Viabahn implantation for iatrogenic complications.