A 76-year-old male was admitted for right sural claudication. Aneurysmectomy of the abdominal aorta had been performed 10 years earlier, with an open surgical placement of an aorto-bi iliac dacron graft (18x9mm). The angio-CT scan of the abdomen and lower limbs (Fig. 1) showed that the aorta had a diameter of 25 mm at the distal III, with a mural thrombus, that markedly reduced the flow in the terminal pre-carrefour tract to about 5–6 mm. The left iliac axis presented post-stenotic ectasia up to 16 mm. A 2 cm occlusion of the right common iliac artery was observed, after which the vessel was re-opacified to the distal III due to revascularization by hypertrophic collateral circulation coming from the contralateral hypogastric artery. The right common femoral artery was patent and presented a 7-mm-thick thrombotic apposition. The deep and superficial femoral artery were patent, without non-conditioning atheromasia or significant morphological stenosis. On the left, there was regular patency of the superficial femoral artery and deep common femoral artery.
It was decided to proceed with a bilateral common femoral arterial approach, with a 6 Fr introducer sheath on the left side and 8 Fr introducer sheath on the right side, after local anesthesia and systemic heparinization (5000 UI). Preliminary angiography via the left common femoral artery confirmed and highlighted the occlusion of the aortic carrefour (Fig. 2a, b). The occlusion of the left common iliac artery was passed using a 5 Fr catheter and 0.035”guidewire. After several unsuccessful attempts were made to cross the occlusion of the right common iliac artery due to lumen obstruction by folds of fabric from the collapsed graft wall. The GoBack catheter 4 Fr with 0.018″ guidewire ASAHI Gladius MG 18 PV ES (Asahi Intecc, Nagoya - Japan), was deployed to create a lumen through the graft fabric, inserted from the right common femoral artery and advanced to the desired location. The needle was then extended to 5–7 mm and aimed and pushed. The radio-opaque marker on the needle’s distal section provides guidance as to the needle tip axial and radial position so the GoBack needle was precisely oriented to easily cross the occlusion (Fig. 2c). Thereafter, a 6 Fr guiding catheter was inserted and pre-dilation was performed (Fig. 3a) with the low-profile Passeo-35 Xeo balloon catheter (BIOTRONIK AG, Bülach - Switzerland) to 4 mm and 5 mm, and then subsequently inflated to 8 mm. Aortoiliac kissing stents were then deployed (Fig. 3b). On the right side, Covera™ Vascular (BD, Franklin Lakes – USA) covered stent (10 × 60 mm) was placed imbricated with an Astron (BIOTRONIK AG) bare-metal stent (10 × 40 mm), with distal landing in the external ipsilateral iliac artery. On the left side, an Epic™ (Boston Scientific Corporation, Natick - USA) vascular self-expanding stent (10 × 60 mm) was inserted. Post-dilation was performed at 10 mm. The final angiographic assessment showed resolution of the occlusion, restored direct flow and increased distal flow, without any complications. Previous sural claudication was resolved andCT-scan follow up at 1 month and DUS follow up at 3 months confirmed the patency of ilio-femoral axis with triphasic flow (Fig. 3c).
