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Live Case #6 : Percutaneous bypass for long femoral-popliteal occlusion

Case of the month: April 2021

This didactic procedure regards a 60 years old man presenting a severe left lower limb claudication with rest pain (stage 3). The patient has a history of two femoro-infrapopliteal venous bypasses which both occluded shortly after. Multimodality imaging revealed a long occlusion of the femoropopliteal axis with a severely diseased posterior tibial artery. A previous antegrade attempt of recanalization failed due to severe calcification. No retrograde attempt was done due to severe claudication. The patient has finally undergone a percutaneous femoropopliteal bypass.


Educational objectives

  • Define the indication of percutaneous femoro-popliteal bypass (PFPB) in severe lower limb disease.
  • Plan a step-by-step procedure of PFBP.
  • How to manage antegrade and retrograde access?
  • How to choose the accurate spots for the implantation of PFPB: proximal and distal implantation.
  • Selecting the appropriate devices : guidewires, microcatheters, guiding catheter, balloons and covered stents
  • How to modify a guiding catheter for a coaxial transseptal needle system?
  • How to safely perform a puncture using transseptal needle through occluded femoral artery.
  • How to safely perform an externalization and extra-vessel trajectory?
  • Tips and tricks to a successful puncture and reentry.
  • What are adjunctive pharmacotherapies?


Step-by-step procedure: supra-articular femoropopliteal percutaneous bypass

1) Access sites:

  • Antegrade femoral access: 6 French sheath and 8 French sheath for final stenting.
  • Retrograde access through the anterior tibial artery (ATA).

2) Retrograde recanalization:

  • V-18™ wire and Terumo 0.035” angled stiff Glidewire® with the support of TrailBlazer™ microcatheter.
  • Advancement of knuckled wire through tibioperoneal trunk (TPT) subintimally until the landing zone (distal third of left superficial femoral artery (FSA))
  • Pre-dilatation: OTW Armada balloons : 3*60 mm then 5*60 mm.

3) Preparation of the landing zone:

  • Predilatation: OTW Armada balloon 5*60 mm.
  • Use the balloon in place to identify the landing zone..

4) Preparation of the transseptal needle:

  • 6 French guiding catheter cut to obtain a shorter one at the level of the transseptal needle curve
  • Insertion of the transseptal needle in the modified 6 French guiding catheter to protect the needle (avoid vessel perforation or dissection).
  • Coaxial system: direct the transseptal needle and puncture safely.

5) Externalisation and extravessel trajectory :

  • Puncture of the vessel wall toward the medial side of the proximal cap of the occluded vessel (avoid collateral vessels).
  • Injection of diluted Lidocaïne (0.1%) locally.
  • Advancement of the knuckled Terumo 0.035’’ angled Glidewire® into the extravascular space, paralleled to the native vessel (following calcifications) with the support of the guiding catheter.

6) Reentry

  • Balloon dilatation from retrograde access at the reentry site (REVERSE CART technique).
  • Puncture at the reentry site: balloon and guidewire from retrograde access serve as a benchmark, and orthogonal views.
  • Pre-dilatation of the reentry site: Armada OTW balloon 4*60 mm
  • Positioning of the guiding catheter downstream to the reentry site, inside the vessel structure.

7) Stenting:

  • Exchange to a support guidewire: Lunderquist Extra Stiff 0.035’’ guidewire.
  • Exchange to an 8 French sheath 45cm which is advanced downstream to the distal reentry point.
  • Stenting the reentry point: Covera™ stent 6*100 mm.
  • Stenting the extra-vessel trajectory: Viabahn®7*150 mm with long overlapping.
  • Stenting the exit point Viabahn® 7*80 mm with long overlapping.

8) Antegrade angioplasty:

  • Predilatation and stenting of the popliteal artery.
  • Remove ATA sheath and balloon hemostasis.

9) Post dilatation of the covered stents

10) Medical adjunctive treatments

  • Pre-procedural: Heparin and Antibioprophylaxis.
  • Post procedural: Triple therapy: Aspirin 75mg o.d. + Clopidogrel 75mg o.d. + Enoxaparin 100 UI/kg b.i.d. : 15 days.
  • DUS 15 days after.
  • Stop Clopidogrel and continue Aspirin 75mg b.i.d and NAOC.



4.  Giannopoulos S, Lyden SP, Bisdas T, Micari A, Parikh SA, Jaff MR, et al. Endovascular Intervention for the Treatment of Trans-Atlantic Inter-Society Consensus (TASC) D Femoropopliteal Lesions: A Systematic Review and Meta-Analysis. Cardiovasc Revasc Med. janv 2021;22:52‑65.

5.  Constans J, Bura-Rivière A, Visona A, Brodmann M, Abraham P, Olinic D-M, et al. Urgent need to clarify the definition of chronic critical limb ischemia – a position paper from the European Society for Vascular Medicine. Vasa. 1 mai 2019;48(3):223‑7.

6.  Krievins DK, Halena G, Scheinert D, Savlovskis J, Szopiński P, Krämer A, et al. One-year results from the DETOUR I trial of the PQ Bypass DETOUR System for percutaneous femoropopliteal bypass. J Vasc Surg. nov 2020;72(5):1648-1658.e2.

7.  Kedora J, Hohmann S, Garrett W, Munschaur C, Theune B, Gable D. Randomized comparison of percutaneous Viabahn stent grafts vs prosthetic femoral-popliteal bypass in the treatment of superficial femoral arterial occlusive disease. J Vasc Surg. janv 2007;45(1):10‑6.

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