After predilation, we implanted two rapid-exchange 6.0–100 mm R2P Misago stents (Terumo, Tokyo, Japan) with a 200-cm long shaft system in the CTO lesion of the right SFA (Fig. We successfully crossed the wire into the CTO lesion of the right SFA, and we dilated the lesion with a 4.0–100 mm Metacross rapid-exchange balloon catheter (Terumo, Tokyo, Japan) (Fig. We advanced a 0.014 inch Halberd guidewire (Asahi Intecc, Nagoya, Japan) with a 2.5 Fr 150-cm long Corsair Armet microcatheter (Asahi Intecc, Nagoya, Japan) into the right SFA. Initial angiography showed total occlusion of the left SFA from the ostium to the distal portion (Fig. After insertion of a 7 Fr R2P Glidesheath slender sheath and advancement of a 7 Fr 120-cm long SlenGuide catheter into the right iliac artery, the patient was fixed in Fowler’s position with the Vac-Lok fixation device (Fig. We considered that she would still need to be in Fowler’s position on the catheterization table during PVI to prevent worsening HF. We decided to perform PVI for revascularization of the right SFA during this hospitalization because of severe pain uncontrolled by pain relief medicines. She was diagnosed as critical limb ischemia (clinical limb stage: Fontaine III). A computed tomography (CT) angiogram showed chronic total occlusion (CTO) of the right superficial femoral artery (SFA) and left external iliac artery (Fig. The ankle-brachial index (ABI) was unmeasurable at rest. Physical findings showed absent pedal pulses, and shiny smooth, pallor, cold skin of the right leg. Although her symptoms for HF had improved after resting in Fowler’s position and treatment with diuretics, beta blockers, and angiotensin-converting enzyme inhibitors, she complained of rest pain in her right lower leg 1 week after admission. She had been diagnosed with PAD at 73 years of age, and she underwent amputation surgery above the left knee owing to ischemic and diabetic necrosis 1 year prior. The patient had a medical history of diabetes mellitus and smoking. (Fig.1c, 1c, d).Ī 75-year-old Japanese female (height: 150 cm weight: 43 kg) was emergently admitted to our hospital for worsening HF due to ischemic cardiomyopathy, with a left ventricular ejection fraction less than 35%. After the vascular access procedure was completed, the patient’s upper body was fixed at a 45° angle (so-called Fowler’s position) with a Vac-Lok fixation device (Fig. The 6 Fr R2P Destination slender sheath needs to be directly advanced into the right or left iliac artery, if possible, and into the femoral artery with a 0.035 inch Rafifocus stiff long guidewire. It has been developed for radial access, and it is specifically designed to have greater flexibility and tracking. The 6 Fr R2P Destination slender sheath is relatively new. This guiding catheter also has a thin-walled design and thin inner lumen to accommodate balloons or stents. To position the 7 Fr R2P Glidesheath sheath, a 7 Fr 120-cm long R2P SlenGuide guiding catheter (Terumo, Tokyo, Japan) needs to be inserted into the sheath and advanced to the right or left iliac artery using a 0.035 inch Rafifocus stiff J-shaped 380-cm long guidewire (Terumo, Tokyo, Japan). The 7 Fr R2P Glidesheath slender sheath has a thin-walled layer, and the outer diameter is the same size as that of current 6 Fr sheaths. A sheath was inserted into the left RA, either a 7 Fr 16-cm long R2P Glidesheath ® slender sheath (Terumo, Tokyo, Japan) or a 6 Fr 119- or 149-cm long R2P Destination slender sheath (Terumo, Tokyo, Japan). This device has been developed and specialized for treatment of lower-extremity PAD via radial access. Fig.1b, 1b, the left radial artery (RA) was selected as the vessel access site with the R2P system (Terumo, Tokyo, Japan). The Creative Commons Public Domain Dedication waiver ( ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.Įach patient was initially put in the supine position on the catheterization table with a Vac-Lok fixation device (CIVCO Medical Solutions, Orange City, IA), opposite from the C-arm of the X-ray machine (Fig. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.
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