LAUSR

Chronic juxta-renal aorto-iliac occlusion (JRO) represents the most severe form of; aorto-iliac occlusive disease, classified under TransAtlantic Inter-Society Consensus (TASC II) as a TASC II D lesion with surgical treatment as the main recommendation. While endovascular revascularization of other TASC II D lesions are routinely performed, JRO is often considered a contraindication for endovascular treatment due to the extensive nature, extending from the level of the renal arteries down to the iliac arteries. We hereby illustrate an IVUS guided re-entry based technique to facilitate endovascular reconstruction of a JRO. A 58-year-old man with JRO presented with an infected non-healing forefoot ulcer. A trans-radial pig-tail catheter was positioned at the level of the occlusion as an imaging catheter and landmark for re-entry. Subintimal wiring was performed through bilateral groin accesses to the level of the pig-tail catheter. Intra-vascular guided re-entry catheter was used to identify the true lumen guide firing of the needle catheter, allowing passage for a guidewire into the true lumen of the supra-renal aorta. The intimal fenestration was dilated using a 4 mm angioplasty balloon which allowed passage of the contralateral guidewire. Kissing-stent grafts were deployed bilaterally, extending from the level of the infra-renal aorta down to the level of the distal external iliac arteries in overlapping fashion. Completion angiography showed brisk flow from the aorta through the stented portion into the femoral arteries. The patient underwent forefoot amputation two days later with successful wound healing and limb salvage at 6 months.