Intravascular Ultrasound-assisted Crosser System through the Retrograde Approach to Treat a Trans-atlantic Inter-society Consensus D Lesion in the Superficial Femoral Artery after Graft Failure.

Background: The crosser system is useful to treat chronic total occlusion (CTO) lesions refractory to guidewire recanalization. However, the Inter-Society Consensus for the Management of Peripheral Arterial Disease recommends bypass graft surgery for Trans-Atlantic Inter-Society Consensus (TASC) type D femoropopliteal (FP) lesions. This approach may not be practical in patients with previous graft failure. In these patients, endovascular therapy with the crosser system may be appropriate. However, there are few reports of the crosser system to treat CTO after failure of FP bypass grafts. Case Report: A 74-year-old man with a history of 2 FP bypass grafts presented with left lowerlimb ischemic rest pain. Ankle-brachial pressure index (ABPI) in the left leg was 0.45. Angiography revealed a TASC type D lesion in the left superficial femoral artery (SFA). A bidirectional approach was used, but the very stiff dedicated CTO guidewire could not pass through the lesion. Therefore, after confirming that the guidewire was in the true lumen by intravascular ultrasound (IVUS), we used a CROSSER (R) 14S catheter (Bard Peripheral Vascular Inc., Tempe, AZ) through the retrograde route in the popliteal artery. The lesion was crossed, and a stent was successfully implanted. The patient's symptoms of rest pain resolved with an improved ABPI in the left leg of 0.82 after the procedure. Conclusions: The crosser system assisted by IVUS through the retrograde approach was useful to treat CTO in the SFA after failure of FP bypass grafts.