Shinshu Med J, 59 ⑵ :97〜102, 2011

Penetration of Calciﬁ
ed Lesions in Chronic Total Occlusion Usinga Brockenbrough Needle
Yusuke MIYASHITA
Department of Cardiovascular Medicine and Advanced Cardiovascular Center,
Shinshu University Graduate School of Medicine

Endovascular treatment of calciﬁed and occluded lesions remains a challenge. Dense calciﬁcations in
occlusive lesions hinder the advancement of guidewires, angioplasty balloon catheters, and stenting. We
present a technique of piercing calciﬁcations in a patient with chronic total occlusion (CTO)of the superﬁcial
femoral artery(SFA)using a Brockenbrough needle.The case was a 79 ‑year‑old man with resting pain in theleft leg for a month.The ankle‑brachial index in his left lower limb was 0.45.Duplex scanning and angiography
revealed complete occlusion of the proximal left SFA. Endovascular treatment for the recanalization of the
SFA‑CTO was carried out using the bidirectional approach. Only the coronary CTO wire was able to crossthe lesion,with the balloon catheters failing to cross.To widen the crossing site,a Brockenbrough needle wasapplied to penetrate the lesion. The needle successfully passed the lesion, and balloon passage was possible.
Following predilatation, we deployed two Nitinol self‑expandable stents. We conﬁrmed the patency of thislesion with duplex sonography and angiogram 18 months later. Shinshu Med J 59 : 97 ―102, 2011
(Received for publication November 19, 2010;accepted in revised form January 17, 2011)
Key words:angioplasty, chronic total occlusion, claudication, peripheral arterial disease

Introduction

occlusive disease. However, heavily calciﬁed andoccluded SFA disease remains a challenge for the

Patients with peripheral arterial disease suﬀer

endovascular approach. Advancement of the guid-

substantial functional disability through claudica-ewire, balloon catheters, or stent delivery systemtion, rest pain, or tissue loss. Exercise, rehabilita-

are extremely diﬃcult in densely calciﬁed SFAtion, drug therapy, and percutaneous or surgicalchronic total occlusion (CTO).Even after successful

revascularization are the current therapeutic

wire passage,the balloon catheter or stent may not

options for these symptomatic peripheral arterial

cross the lesions.We applied a technique of piercing

disease patients.

calciﬁcations in a patient with CTO of the SFA

With continuing advances in imaging techniques,angioplasty equipment,and endovascular expertise,
the management of patients with superﬁcial femoral

using a Brockenbrough needle after wire passage.
Caseartery (SFA) occlusive disease has dramaticallyA 79 ‑year‑old man with hypertension, hyper-changed.In recent years angioplasty has come to belipidemia, and coronary artery disease presented

considered the primary treatment strategy for SFA

with complaints of resting pain in the left leg forone month. The ankle‑brachial index of his left

Corresponding author:Yusuke M iyashita
Department of Cardiovascular M edicine and Advanced
Cardiovascular Center, Shinshu University Graduate

lower limb was 0.45. Even after 200 mg/day of
Cilostazol was given, the pain in the limb was not

School of M edicine, 3‑1‑1, Asahi, Matsumoto‑city,

alleviated. Duplex scanning and angiography ofNagano‑prefecture, 390‑8621, Japanthe lower extremity showed the complete occlusion

No. 2, 201197

Yusuke M iyashita

Ａ

Ｂ

Fig.1 Control angiogram
Ａ :Severe calciﬁcation of the superﬁcial femoral artery is seen.
White arrows indicate the occluded SFA which was not visualized with contrast.The ostium of the SFA
was completely occluded with dense calcium.
Ｂ :The white arrows indicate the occluded superﬁcial femoral artery.
The occlusion continued to the middle SFA. Only the deposition of calcium indicated the existence of
the SFA.

of the proximal left SFA (Fig. 1). Considering theapplied into the SFA in an antegrade manner.Theseheavily calciﬁed CTO in the SFA, endovascularwires also failed to cross the occluded SFA. We

treatment was carried out byusing the bidirectional

placed a 0.014‑inch antegrade wire as a landmark

approach.The retrograde approach was performed

for the proximal true lumen and a 0.018‑inch ante-

via the left popliteal artery.The patient was placed

grade wire as a landmark for the proximal false

in the prone position,and a 4‑Fr sheath was insert-

lumen.A Conquest pro 8‑20 wire(ASAHI INTECC,

ed into the left popliteal artery under duplex

Nagoya, Japan) was used to try to penetrate theultrasonographic guidance. The patient was thenlesion and successfully crossed the occluded leftturned over and placed in the supine position. The

SFA in a retrograde fashion (Fig. 2).

antegrade approach was performed with a 6‑Fr 45‑

This extra stiﬀwire was subsequently drawn out

cm Ansel‑1 sheath (Cook M edical, Indiana, USA)

into the right femoral sheath by a gooseneck snare

placed in the left external iliac artery via the right(EV3, Minnesota, USA). Bijou 2.0‑20 (Boston

femoral artery.

Scientiﬁc,M assachusetts,USA ),Savvy 2.0‑20(Cor-A 4‑Fr JR 4.0 diagnostic multipurpose catheter

dis, New Jersey, USA)balloon,and Marverick‑2 1.

(M edikit, Tokyo, Japan) was inserted in order to

5‑15 (Boston Scientiﬁc, M assachusetts, USA) wereachieve stronger back‑up support with a guidewire

used to try to cross the occluded SFA. However,through the 6‑Fr Ansel‑1 right femoral sheath.A 4‑

these too failed to pass the occlusion when inserted

Fr multipurpose catheter was inserted from the leftin both the antegrade and retrograde fashions.After

popliteal sheath.A 0.014‑inch guidewire and a 0.018

conﬁrming the position of the 0.014 crossed guid-‑inch guidewire were advanced into the SFA toewire in the true lumen of the left SFA by duplex

cross the SFA‑CTO in a retrograde manner.Theseultrasonography, a Brockenbrough needle was

two wires failed to pass through the occluded seg-advanced through the left popliteal sheath. This

ment. After the failure to pass the wire via the

Brockenbrough needle successfully pierced andretrograde approach, the two guidewires wererecanalized the occluded SFA (Fig. 3). After cross-98

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Penetration of calciﬁed occlusion with Brockenbrough needle

Fig.2 Bidirectional multi‑wire manipulation
A 0.014‑inch guidewire (Ruby) which could not penetrate the occluded lesion in an
antegrade manner was retained as a landmark for the proximal true lumen.A 0.018‑inch
guidewire (Treasure) which went into the dissected lumen in an antegrade manner was
retained as a landmark for the proximal dissected lumen. By using these landmarks, theConquest pro 8‑20 guidewire could penetrate the occluded lesion in a retrograde manner
through the popliteal sheath.

Fig.3 Penetration of the occluded lesion with a Brockenbrough needle through the 0.014 inch wire
A white arrow indicates the tip of the Brockenbrough needle. The Brockenbrough needle was advanced
from the distal to proximal SFA via the popliteal artery.

No. 2, 201199

Yusuke M iyashita

Fig.4 Final angiogram

ing the left SFA with a Brockenbrough needle, aapproach. This strategy is based on the coronary

Savvy 2.0‑20 balloon easily crossed the lesion in a

CTO technique . Recently, wires and balloon cath-retrograde fashion and successfully dilated theeters have been improved and developed with thelesion. After the replacement from the 4‑Fr po-same technologies as the coronary devices.Thus wepliteal sheath to a 6‑Fr popliteal sheath, two

could attempt to treat CTO of the SFA using the

SM ART stents (7.0‑80 mm and 8.0‑80 mm)(Cordis)

same approach as in the case of coronary arterial

were implanted into the SFA. Postdilatation was

occlusion. Using these guidewires, the chance ofperformed by a Synergy 5.0‑40 balloon (Boston) totrue lumen penetration of the chronic occlusion may

dilate the calciﬁed SFA lesion,with a ﬁnal pressure

increase. In a severely calciﬁed occlusion,however,up to 24 atm (Fig. 4).

situations in which no balloon catheters can pass theFollowing the successful stent placement in the
SFA‑CTO, the patient was free from rest pain andocclusion even after successful wire passage arelikely to increase, as in our case.

claudication. The ankle‑brachial index of his left

Rotablator is a veryeﬀective tool to treat arterial

limb was 1.05 at 18 months after treatment.Follow‑

stenosis and occlusion due to calciﬁcation . How-up angiography revealed a minor stent fracture

ever, to apply the Rotablator, Rota wire has to bewithout signiﬁcant stenosis (Fig. 5).

inserted. In order to replace Rota wire, the mi-

Discussion

crocatheter or over‑the‑wire balloon must be passed through the occlusion. In our case, it was not

In this case, we applied a Brockenbrough needle

possible to pass the microcathter and the over‑the‑to penetrate a dense calciﬁcation in an occluded

wire balloon catheter. Therefore, the Rotablator in

SFA.This is the ﬁrst case presentation of the use ofthis case was not practical.

a Brockenbrough needle to penetrate an occluded
SFA.
To cross the CTO, we needed a triple wire100

Laser atherectomy may be another option in thiskind of case . However, the eﬀectiveness and thesafety of laser atherectomy in the treatment of
Shinshu Med J Vol.59

Penetration of calciﬁed occlusion with Brockenbrough needleＡ

Ｂ
Fig.5 Follow‑up angiogram at 18 months after the procedure
Ａ :No signiﬁcant in‑stent restenosis is present.
Ｂ :A type‑1 fracture of the stent is seen at the proximal end of the lesion (white arrow).

calciﬁed lesions has not yet been clariﬁed ; more-

Treatment of a bent SFA‑CTO with Brocken-

over, the technique is not available in most coun-brough penetration may be dangerous, as the risks

tries.

of perforation may be higher, especially without

The Brockenbrough needle is simple, and com-conﬁrmation of the wire position.Duplex ultrasono-

monly used.We tried to penetrate the true lumen ofgraphyor intravascular ultrasonographyare needed

this occluded SFA. From the retrograde approach,for conﬁrmation of the wire position before Brock-even after the wire successfully passed the lesion,enbrough penetration.

balloon catheters could not cross the calciﬁed oc-

Sub‑intimal angioplasty is a well‑known strat-

cluded lesion. However, a Brockenbrough needle,

egy for the treatment of SFA‑CTO.However,even

which was inserted from the retrograde route

if we had applied sub‑intimal angioplasty in thisthrough the popliteal artery, easily passed thedensely calciﬁed lesion,the Nitinol self‑expandable

lesion.The use of the Brockenbrough needle maybe

stent might not have expanded and might haveaccompanied by the risk of perforation. However,recoiled because of the presence of dense

the SFA is ideal for using the Brockenbrough needle

calciﬁcations even after successful balloon dilata-

via the popliteal artery because the SFA is ation.

straight vessel.M oreover,we conﬁrmed the position

We introduced the successful use of a Brocken-of the wire using duplex ultrasonography,and there-brough needle to penetrate an occlusion with dense

fore the risk of perforation in this case wascalcium in this paper. This method may be one ofextremely low. The needle only followed the wire

the options for treating a densely calciﬁed SFO‑

which was assumed to be in the true lumen.

CTO.

No. 2, 2011101

Yusuke M iyashita

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（2010.11.19 received ; 2011. 1.17 accepted）

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