Supera Stent Implantation with Ultrasound Guidance for Complex Ostial Lesions of Superficial Femoral Artery by Retrograde Approach: The SUGAR Technique

Abstract

Purpose The aim of this study was to describe a modified technique for accurate deployment of the Supera stent under ultrasound (US) guidance for complex lesions involving superficial femoral artery (SFA) ostium without jailing profunda femoral artery (PFA) by retrograde approach.

Technique Retrograde pedal access was initially taken in all the cases. The stenotic or occlusive femoropopliteal lesions involving the SFA ostium were crossed retrogradely and additional contralateral common femoral artery (CFA) access was taken only if we failed to cross the lesion. In addition to fluoroscopy, extravascular US guidance was freely used whenever required throughout the procedure. After desired predilatation of the SFA lesion, US guidance (gray scale and color Doppler) was used to start deployment of the proximal few centimeters of Supera stent ensuring that the landing of first crown was exactly from the SFA ostium not extending into CFA or jailing the PFA ostium. The rest of the stent was deployed under fluoroscopic guidance. Retrograde pedal access site hemostasis was achieved by manual compression. The Supera stent implantation with Ultrasound Guidance for complex ostial lesions of superficial femoral Artery by Retrograde approach (SUGAR) technique was applied successfully in 35 patients (mean age 58.1 ± 4.4 years; 24 males) with critical limb ischemia via the distal pedal approach. No access site or remote complications were observed.

Conclusion The SUGAR technique has superior advantage of utilizing a simple tool like extravascular US in addition to fluoroscopy for retrograde Supera stent deployment by allowing very precise landing at SFA ostium, bypassing the need for multiple oblique projections, unwanted radiation exposure, and extra contrast dye overload.

Keywords

plain old balloon angioplasty - vasculomimetic - ostial lesion - retrograde pedal access - superficial femoral artery - profunda femoral artery - stent

Publication History

Article published online:
21 May 2021

• References

• 1 Scheinert D, Scheinert S, Sax J. et al Prevalence and clinical impact of stent fractures after femoropopliteal stenting. J Am Coll Cardiol 2005; 45 (02) 312-315
• 2 Yamawaki M, Hirano K, Nakano M. et al Deployment of self-expandable stents for complex proximal superficial femoral artery lesions involving the femoral bifurcation with or without jailed deep femoral artery. Catheter Cardiovasc Interv 2013; 81 (06) 1031-1041
• 3 Jaff MR, White CJ, Hiatt WR. et al TASC Steering Committee. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: a supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Endovasc Ther 2015; 22 (05) 663-677
• 4 Duda SH, Bosiers M, Lammer J. et al Drug-eluting and bare nitinol stents for the treatment of atherosclerotic lesions in the superficial femoral artery: long-term results from the SIROCCO trial. J Endovasc Ther 2006; 13 (06) 701-710
• 5 Krankenberg H, Schlüter M, Steinkamp HJ. et al Nitinol stent implantation versus percutaneous transluminal angioplasty in superficial femoral artery lesions up to 10 cm in length: the Femoral Artery Stenting Trial (FAST).. Circulation 2007; 116 (03) 285-292
• 6 Zeller T, Tiefenbacher C, Steinkamp HJ. et al Nitinol stent implantation in TASC A and B superficial femoral artery lesions: the Femoral Artery Conformexx Trial (FACT). J Endovasc Ther 2008; 15 (04) 390-398
• 7 Schillinger M, Sabeti S, Loewe C. et al Balloon angioplasty versus implantation of nitinol stents in the superficial femoral artery. N Engl J Med 2006; 354 (18) 1879-1888
• 8 Dake MD, Scheinert D, Tepe G. et al Zilver PTX Single-Arm Study Investigators. Nitinol stents with polymer-free paclitaxel coating for lesions in the superficial femoral and popliteal arteries above the knee: twelve-month safety and effectiveness results from the Zilver PTX single-arm clinical study. J Endovasc Ther 2011; 18 (05) 613-623
• 9 Laird JR, Katzen BT, Scheinert D. et al RESILIENT Investigators. Nitinol stent implantation vs. balloon angioplasty for lesions in the superficial femoral and proximal popliteal arteries of patients with claudication: three-year follow-up from the RESILIENT randomized trial. J Endovasc Ther 2012; 19 (01) 1-9
• 10 Bosiers M, Torsello G, Gissler HM. et al Nitinol stent implantation in long superficial femoral artery lesions: 12-month results of the DURABILITY I study. J Endovasc Ther 2009; 16 (03) 261-269
• 11 Sabeti S, Mlekusch W, Amighi J, Minar E, Schillinger M. Primary patency of long-segment self-expanding nitinol stents in the femoropopliteal arteries. J Endovasc Ther 2005; 12 (01) 6-12
• 12 Laird JR. Limitations of percutaneous transluminal angioplasty and stenting for the treatment of disease of the superficial femoral and popliteal arteries. J Endovasc Ther 2006; 13 (Suppl. 02) II30-II40
• 13 Laird JR, Katzen BT, Scheinert D. et al RESILIENT Investigators. Nitinol stent implantation versus balloon angioplasty for lesions in the superficial femoral artery and proximal popliteal artery: twelve-month results from the RESILIENT randomized trial. Circ Cardiovasc Interv 2010; 3 (03) 267-276
• 14 Dake MD, Ansel GM, Jaff MR. et al Zilver PTX Investigators. Paclitaxel-eluting stents show superiority to balloon angioplasty and bare metal stents in femoropopliteal disease: twelve-month Zilver PTX randomized study results. Circ Cardiovasc Interv 2011; 4 (05) 495-504
• 15 Werner M, Paetzold A, Banning-Eichenseer U. et al Treatment of complex atherosclerotic femoropopliteal artery disease with a self-expanding interwoven nitinol stent: midterm results from the Leipzig SUPERA 500 registry. EuroIntervention 2014; 10 (07) 861-868
• 16 Scheinert D, Grummt L, Piorkowski M. et al A novel self-expanding interwoven nitinol stent for complex femoropopliteal lesions: 24-month results of the SUPERA SFA registry. J Endovasc Ther 2011; 18 (06) 745-752
• 17 Scheinert D, Werner M, Scheinert S. et al Treatment of complex atherosclerotic popliteal artery disease with a new self-expanding interwoven nitinol stent: 12-month results of the Leipzig SUPERA popliteal artery stent registry. JACC Cardiovasc Interv 2013; 6 (01) 65-71
• 18 Piorkowski M, Freitas B, Schmidt A. et al The use of the GORE® TIGRIS® Vascular Stent with dual component design in the superficial femoral and popliteal arteries at 6 months. J Cardiovasc Surg (Torino) 2013; 54 (04) 447-453
• 19 Palena LM, Diaz-Sandoval LJ, Raja LM, Morelli L, Manzi M. Precise retrograde Supera stenting of the ostium (PRESTO) of the superficial femoral artery for complex femoropopliteal occlusions: the PRESTO technique. J Endovasc Ther 2018; 25 (05) 588-591