Heavily calcified chronic total occlusion ofcommon iliac artery successfully treated withTornus microcatheter and rotational atherectomyMasahiko Hara, MD, Masami Nishino, MD, PhD, Ken Matsuoka, MD, and Yoshio Yamada, MD, PhD,Sakai, Osaka, Japan

A 58-year-old man who required long-term hemodialysis was referred to our institution for the management oflife-limiting intermittent claudication of the right lower extremity. The diagnostic arteriography demonstrated heavilycalcified chronic total occlusion in the right common iliac artery. The lesion was successfully treated with the combinationof a Tornus microcatheter (Asahi Intecc, Aichi, Japan) and rotational atherectomy. We describe in this article a nicheapplication of the Tornus microcatheter and the effect of the combination technique of it with rotational atherectomy in

peripheral interventions. ( J Vasc Surg 2008;48:758-60.)

There are still some cases of failure to recanalize chronictotal occlusion (CTO) during peripheral interventions, de-spite the use of newly available devices.1 One of the causesof failure is the inability to cross the lesion with a balloonangioplasty catheter. The use of the Tornus microcatheter(Asahi Intecc, Aichi, Japan) to overcome this limitation hasrecently been approved by the United States Food andDrug Administration (Fig 1).2 We describe a patient with aheavily calcified CTO of the common iliac artery (CIA) thatcould not be crossed with a 1.5-mm balloon angioplastycatheter but was successfully treated by combination of aTornus microcatheter and rotational atherectomy.

TECHNICAL NOTE

A 58-year-old man, who required long-term hemodi-alysis and had a history of stent implantation in the left CIA,was referred to our institution for the management oflife-limiting Fontaine class IIb intermittent claudication ofthe right lower extremity. The ankle-brachial index showedlow values of 0.67 in the right leg, and diagnostic arteriog-raphy demonstrated a heavily calcified CTO in the rightCIA. After a cardiovascular interventionist and vascularsurgeon provided a detailed explanation of all therapeuticchoices, he decided to undergo endovascular interventions.

Initially, we inserted a 4F sheath in the left commonfemoral artery from which we advanced a 4.2F pigtailcatheter (Goodman, Aichi, Japan) into the terminal portionof the aorta for contrast medium injection during theintervention (Fig 2, a). Then, the retrograde right commonfemoral approach was performed with a 6F sheath. Wecould cross the lesion with an 0.018-inch Astato guidewire(Asahi Intecc; Fig 2, b), using a 4.2F internal mammary

From the Division of Cardiology, Osaka Rosai Hospital.Competition of interest: none.Reprint requests: Masahiko Hara, MD, Osaka Rosai Hospital, 1179-3

Nagasone-cho, Kita-ku, Sakai, Osaka 591-8025, Japan (e-mail:wpgjq774@yahoo.co.jp).

0741-5214/$34.00Copyright © 2008 by The Society for Vascular Surgery.

doi:10.1016/j.jvs.2008.05.059

758

artery catheter (Goodman, Aichi, Japan) for guidance and a2.4F Progreat microcatheter (Terumo, Tokyo, Japan) foradditional backup force. However, neither the Progreatmicrocatheter nor the 2.0- � 20-mm Savvy balloon cathe-ter (Cordis, Warren, NJ) was able to cross the lesion. Thelesion was also resistant to crossing with a 1.5- � 6-mmover-the-wire Sprinter coronary balloon catheter (Medtronic,Minneapolis, Minn), even though a “buddy wire” tech-nique3 was attempted using a 0.014-inch ATHLETERUBY guidewire (Japan Lifeline, Tokyo, Japan). We there-fore removed the 0.018-inch guidewire and the 1.5- �6-mm coronary balloon catheter. A 2.1F Tornus penetra-tion microcatheter was advanced into the vessel by rotatingthe device counterclockwise, using the 0.014-inch guide-wire, and we were finally able to cross the lesion (Fig 2, c).

Because the attempt to advance a 1.5- � 6-mm coro-nary balloon catheter after removing the Tornus micro-catheter was unsuccessful, w e recrossed the lesion withthe Tornus microcatheter to exchange the guidewire toRotaWire floppy (Boston Scientific, Natick, Mass), whichis compatible with Rotablator (Boston Scientific), becauseof its stiffness. Rotational atherectomy and balloon angio-plasty were performed using a 1.75-mm Rotablator (Fig 2,d), a 6.0- � 20-mm Sasuga semi-compliant balloon (Bos-ton Scientific), and 9.0- � 20-mm Opta Pro compliantballoon (Cordis).

According to quantitative assessments using intravascu-lar ultrasound (IVUS; Volcano, Rancho Cordova, Calif;Fig 3, a and b), we implanted a 7.0- � 57-mm Expressballoon-expandable nitinol stent (Boston Scientific). Be-cause IVUS identified stent under-expansion, we used a9.0- � 20-mm balloon at a pressure of 8 atm as a postdila-tation technique. The pressure gradient across the lesionbecame 10 mm Hg, and final IVUS demonstrated roundsymmetrical expansion of the stent and sufficient aorticlumen, with a minimum stent diameter of 7 mm (Fig 3, cand d). Final arteriography showed satisfactory morpho-logic results (Fig 2, e). The ankle-brachial index increased

from 0.67 to 1.06 in the right extremity and was main-

d rotion r

JOURNAL OF VASCULAR SURGERYVolume 48, Number 3 Hara et al 759

tained at a 3-month follow-up examination. The patientwas free of symptoms during this period.

DISCUSSION

Patients undergoing treatment for symptomatic pe-ripheral arterial disease may often present with CTO, andthere are still some cases of failure to recanalize the lesion,despite advances in technology.1 Diffuse severe calcifica-tion, which may often be present in patients receivinglong-term hemodialysis,4 may be one of causes of proce-dural failure after successful guidewire passage, althoughit is rare. These limitations, which are common in percu-taneous coronary intervention (PCI), have led to thedevelopment of new devices. The Tornus microcatheterand rotational atherectomy device are among these newtechnologies.

The Tornus microcatheter is made of eight pieces ofstainless steel wire rope in a spiral structure that provideshigh penetration power through its screwing effect and cancross the lesion by rotating counterclockwise manually

Fig 1. Top, Schematic illustration and (Bottom) phomicrocatheter. It is made of eight pieces of stainless steelpower through its screwing effect.

Fig 2. a, Arteriogram demonstrates a heavily calcified chwe managed to cross a guidewire using a 6F longmicrocatheter. c, Because the microcatheter and 1.5- � 6the Tornus penetration microcatheter (Asahi Intecc, Aicha RotaWire floppy (Boston Scientific, Natick, Mass), animplantation. e, Final arteriography after stent implantat

along the 0.014-inch guidewire (Fig 1). Because the Tor-

nus microcatheter gaps the lesions after passing through it,this device may facilitate subsequent balloon catheter cross-ing. It is also designed for device-associated guidewireexchanges for rotational atherectomy, as in this patient, andhas been shown to be effective in the treatment of CTOduring PCI.5

The development concept of the Tornus microcatheter istotally different from the development concept of true-lumenre-entry devices such as the OutBack LTD (Cordis) andPioneer (Medtronic, Santa Rosa, Calif). However, the Tornusmicrocatheter may have the potential to facilitate true-lumenre-entry from the subintimal space by supporting the guide-wire. Besides, it is assumed to be safe in clinical use because itis designed to self-destruct at the proximal part of the shaft toavoid vessel injuries if excessive rotational force is applied. Thelimitation is that the handling time should be limited becausethe wire lumen of this catheter is always exposed to the blooddue to clearance gaps between each single wire, which maylead to thrombus formation in the catheter and may result inrestriction of the wire movement.5 A larger-profile 2.6F Tor-

ph show the 2.1F Tornus (Asahi Intecc, Aichi, Japan)ope into a spiral structure that provides high penetration

total occlusion of the right common iliac artery. b, First,h, 4.2F internal mammary artery catheter, and 2.4Fballoon catheter could not cross the lesion, we advancedan) into the vessel. d, We exchanged the guidewire withational atherectomy was performed, which led to stentevealed satisfactory morphologic results.

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JOURNAL OF VASCULAR SURGERYSeptember 2008760 Hara et al

Although no studies have been published about theTornus microcatheter and only a few about rotationalatherectomy in peripheral interventions,6 these devices areuseful for heavily calcified CTOs in PCI.5,7 Microemboli-zation in rotational atherectomy usage can occasionally beseen in an elevation of creatinine kinase during PCI; how-ever, because the peripheral arterial bed is much larger thanthe coronary bed and most particulate debris is enoughsmall to avoid distal embolization in theory,8 we speculatedthat we could use this device without too much troubleeven though its usage is off-label.

In the present case, we finally succeeded in recanalizinga heavily calcified CTO using a combination of the Tornusmicrocatheter and rotational atherectomy. IVUS has alsocontributed to the interventional success. In our experi-ences, the ideal stent diameter in heavily calcified lesions forboth sufficient recanalization and prevention of complica-tions may be 70% to 80% of the length of the referencediameter measured by IVUS. We also treated the lesion byinflating a balloon carefully and gradually. If the ballooninflation causes pain, a suboptimal result should be ac-cepted because it may imply an overexpansion of the arteryand may be a sign of rupture. Stent grafts should beavailable for the management of rupture or perforation.Laser atherectomy also may be useful to facilitate crossingof CTOs even though its effectiveness for the treatment ofhighly calcified lesions is still unknown.1,6

CONCLUSION

We have reported a heavily calcified CTO of the CIAthat was successfully treated by a combination of a Tornus

Fig 3. Before stenting, the (a) short-axis and (b) long-acalcified stenotic lesions. Quantitative assessments using Ireference diameter of the proximal portion of the lesion wawas 45 mm. After stenting with a postdilatation technique,round symmetrical expansion of the stent and a sufficient a

microcatheter and rotational atherectomy. We believe that

this combination technique may be useful and effective forheavily calcified CTO lesions during peripheral interven-tions. Further studies are needed to confirm our conclu-sions.

REFERENCES

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2. Ho PC. Successful percutaneous interventions with limited crossing ofthe penetration catheter into severe coronary artery stenoses. J InvasiveCardiol 2007;19:E51-4.

3. Burzotta F, Trani C, Mazzari MA, Mongiardo R, Rebuzzi AG, Buffon A,et al. Use of a second buddy wire during percutaneous coronary inter-ventions: a simple solution for some challenging situations. J InvasiveCardiol 2005;17:171-4.

4. Graziani L, Silvestro A, Bertone V, Manara E, Alicandri A, Parrinello G,et al. Percutaneous transluminal angioplasty is feasible and effective inpatients on chronic dialysis with severe peripheral artery disease. NephrolDial Transplant 2007;22:1144-9.

5. Tsuchikane E, Katoh O, Shimogami M, Ito T, Ehara M, Sato H, et al.First clinical experience of a novel penetration catheter for patients withsevere coronary artery stenosis. Catheter Cardiovasc Interv 2005;65:368-73.

6. Rogers JH, Laird JR. Overview of new technologies for lower extremityrevascularization. Circulation 2007;116:2072-85.

7. Silber S, Albertsson P, Aviles FF, Camici PG, Colombo A, Hamm C, etal. Guidelines for percutaneous coronary interventions. The Task Forcefor Percutaneous Coronary Interventions of the European Society ofCardiology. Eur Heart J 2005;26:804-47.

8. Warth DC, Leon MB, O’Neill W, Zacca N, Polissar NL, Buchbinder M.Rotational atherectomy multicenter registry: acute results, complicationsand 6-month angiographic follow-up in 709 patients. J Am Coll Cardiol1994;24:641-8.

ews with intravascular ultrasound (IVUS) showed heavilyrevealed that the minimum lumen diameter was 2 mm,m, distal reference was 9 mm, and the exact lesion length

) short-axis and (d) long-axis views of IVUS demonstratedlumen, with a minimum stent diameter of 7 mm.

xis viVUSs 10 mthe (c

Submitted Mar 15, 2008; accepted May 15, 2008.