Treating complex lesions in tibial and plantar vessels require a unique combination of flexibility and strength. The operator needs to think about wires that can assist in crossing complex long lesions or chronic total occlusions (CTOs). Operators understandably tend to focus on crossing the lesions. However, the wire must be strong enough to deliver revascularization modalities such as atherectomy devices, balloons, and stents. While there is no perfect answer that will achieve all of these capabilities, some wires can get very close. We are going to discuss some of the common wires in our practice. This is mainly to show common examples and by no means excludes other wires not mentioned here. A common wire used routinely is the Viper wire (CSI). What the Viper lacks in CTO crossing, it more than compensates for in other arenas. Beyond its ability to deliver the Diamondback (CSI), it actually has an excellent ability to cross tough lesions, especially in straight segments for both tibial arteries and superficial femoral/popliteal arteries due to its .017-inch tip, which we usually combine with biaxial or triaxial catheters. Another advantage to using the .017-inch variety is its ability to combine with a free-floating filter (in off-label use) like the Nav6 (Abbott Vascular). The Viper wire can be an excellent tool when flossed through an antegrade and pedal access, and in other circumstances, it can be used from contralateral common femoral artery access and flossed through the pedal access. This will afford the operator great abilities to deliver bulky equipment. The length of the Viper wire, at 335 cm, allows the flossing technique to be performed especially with pedal access and contralateral common femoral artery (CFA) access. Another wire we commonly utilize is the V-18 wire (Boston Scientific). We don’t think of the V-18 as an access wire. It is a great wire to start access with and then use to place your sheath in the pedal circulation. Depending on the pedal sheath utilized, the access wires can range in size from .018-inch to .021-inch. However, these wires have a coil tip that makes it difficult to access small, calcified tibial vessels. The V-18 has a soft, shapeable tip with a supportive body. It is also a great wire to use in combination with a supportive catheter in order to create a dissecting loop at the tip of the catheter. We typically refer to this as the JENALI technique (Figure 1). The V-18 wire is supportive enough to deliver .035-inch equipment like balloons and stents. A third favorite is the .014-inch Regalia wire (Asahi Intecc). The Regalia wire is a soft, atraumatic wire that is ideal in pedal loop reconstruction. This wire affords the operator the ability to interrogate the delicate plantar vessels without damaging them. Plantar circulation is a challenging space and using a dedicated CTO wire will almost inevitably destroy the plantar circulation. However, a dedicated CTO wire will be utilized to help penetrate the proximal and distal CTO caps. We generally prefer a .014-inch platform to tackle complex tibial CTOs. The CTO wires are used in proximal to distal tibial vessels. The Astato XS 20-gram wire (Asahi Intecc) is a great tool to tackle tibial CTOs in an antegrade fashion. The Astato .018-inch 30 gram tip wire is an aggressive tool that we use mostly in a retrograde fashion.
The following case will demonstrate the choices we made to tackle a complex anatomical tibial plantar occlusion. We will feature the use of the above-mentioned wires from pedal access, flossing, and pedal loop reconstruction.
This is a 67-year-old male with past medical history significant for diabetes, hypertension and advanced chronic kidney disease (Stage IV). The patient presented with a non-healing ulcer involving the left great toe. The patient was evaluated by podiatry who examined the patient and determined that the arterial flow was impaired. Office ankle-brachial index (ABI) was deemed to be not helpful with non-compressible values. A detailed diagnostic angiogram revealed evidence of an occluded posterior tibial artery (PT) with an occluded dorsalis pedis artery (DP). Visualization of the plantar circulation was limited secondary to a poor collateral system (Figure 2).
In cases where the tibial vessels do not reconstitute above the ankle, we choose to perform a modified Schmidt access of the occluded vessel. This is a technique where the operator accesses the occluded portion of the vessel using ultrasound guidance. Access into the distal occluded PT was performed using a V-18 wire. An antegrade access with a 5 French sheath was utilized to advance an .035-inch Navicross catheter (Terumo) to engage the proximally occluded PT using an Astato .014-inch 20-gram tip wire (Figure 3). Using the tunneling technique, we were able to advance the retrograde V-18 wire into the antegrade Navicross catheter (Figure 4). We chose to floss a Viper wire between the antegrade sheath and the pedal access. After plaque modification in the PT followed by balloon angioplasty, an .014-inch catheter was advanced inside the Navicross over the flossed Viper wire (from the CFA to the PT access point). At this stage, the Viper wire was removed and a Regalia .014-inch wire was advanced into the plantar circulation (Figure 5).
Interestingly, the DP across the ankle joint had what appeared to be a “White Stop Sign”. We have provided an image of the DP under ultrasound and fluoroscopy (Figure 6). The White Stop Sign is a term we use to describe a vessel that is completely opacified with calcified plaque and occupies a long segment of the vessel, making it difficult to cross. In this case, we were able to achieve partial pedal loop reconstruction. This ultimately allowed blood flow to the inferior digital branch, achieving adequate angiosome revascularization (Figures 7-8).
This case highlights the different capabilities of multiple wires in different anatomical locations. It is important for CLI operators to arm themselves with multiple wires they can use in any clinical scenario.
Disclosure: Dr. J.A. Mustapha and Dr. Fadi Saab report that they are consultants for Abbott Vascular, Boston Scientific, CSI, and Terumo Interventional Systems.
The authors can be contacted via Dr. Fadi Saab at email@example.com.