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Impact of Guidewire Route on Severe Dissection After Balloon Angioplasty for Femoropopliteal Chronic Total Occlusion Lesions: An Intravascular Ultrasound Analysis

Open ArchivePublished:February 22, 2021DOI:https://doi.org/10.1016/j.ejvs.2021.01.014

      Objective

      To determine the impact of the guidewire route on severe dissection after balloon angioplasty for femoropopliteal chronic total occlusion (CTO) lesions using a new intravascular ultrasound (IVUS) assessed classification scheme corresponding to a conventional angiographic classification scheme.

      Methods

      Images for 21 femoropopliteal CTO lesions treated endovascularly between May 2018 and December 2019 were used for analysis. IVUS images after guidewire passage and those after balloon angioplasty were evaluated at 1 cm intervals. Cross sectional images were obtained (n = 219) and divided into two groups by the guidewire route: those in which the guidewire passed through the inner half of the luminal radius (central wiring group, 139 cross sectional images) and those in which the guidewire passed through the outer half of the luminal radius (eccentric wiring group, 80 cross sectional images). Angiographically severe dissection was defined as Type C or greater according to the National Heart, Lung, and Blood Institute classification, to which six dissection morphology patterns were applied based on IVUS images (Types A – E2).

      Results

      Central wiring was achieved in an average of 69.6 ± 28.0% of the CTO length from per limb analysis. Among the IVUS assessed dissection morphology patterns, Types D – E2 were more frequently correlated with angiographically severe dissection than were Types A – C (57.5% vs. 13.7%, p < .001). Multivariable analysis showed that soft plaque was a predictive factor for (odds ratio [OR] 2.14; 95% confidence interval [CI] 1.007 – 4.72; p = .048) and central wiring was a protective factor (OR 0.27; 95% CI 0.14 – 0.49; p < .001) against Type D – E2 dissection patterns assessed by IVUS after balloon angioplasty.

      Conclusion

      Lesions with Type D – E2 dissection patterns assessed by IVUS were correlated with angiographically severe dissection. Central wiring may be useful for preventing severe dissection after balloon angioplasty for femoropopliteal CTO lesions.

      Keywords

      Analysis of high definition intravascular ultrasound in this study showed the efficacy of central wiring for preventing severe dissection after balloon angioplasty in femoropopliteal chronic total occlusion lesions. Dissection patterns were classified according to the classification proposed in the coronary intervention field, and lesions with Type D – E2 dissection patterns were correlated with angiographically severe dissection. Guidewire crossing under imaging guidance using duplex ultrasonography may help to achieve central wiring.

      Introduction

      Patency after plain balloon angioplasty has been reported to be affected by the severity of dissection assessed by angiography;
      • Fujihara M.
      • Takahara M.
      • Sasaki S.
      • Nanto K.
      • Utsunomiya M.
      • Iida O.
      • et al.
      Angiographic dissection patterns and patency outcomes after balloon angioplasty for superficial femoral artery disease.
      however, only lesion characteristics have been reported as predictors of such severe dissection.
      • Fujihara M.
      • Takahara M.
      • Sasaki S.
      • Nanto K.
      • Utsunomiya M.
      • Iida O.
      • et al.
      Angiographic dissection patterns and patency outcomes after balloon angioplasty for superficial femoral artery disease.
      Recently, the methodology of balloon angioplasty has been examined in several studies.
      • Tan M.
      • Urasawa K.
      • Koshida R.
      • Haraguchi T.
      • Kitani S.
      • Igarashi Y.
      • et al.
      Comparison of angiographic dissection patterns caused by long vs short balloons during balloon angioplasty of chronic femoropopliteal occlusions.
      • Horie K.
      • Tanaka A.
      • Taguri M.
      • Kato S.
      • Inoue N.
      Impact of prolonged inflation times during plain balloon angioplasty on angiographic dissection in femoropopliteal lesions.
      • Horie K.
      • Tanaka A.
      • Taguri M.
      • Inoue N.
      Impact of scoring balloons on percutaneous transluminal angioplasty outcomes in femoropopliteal lesions.
      • Karashima E.
      • Yoda S.
      • Yasuda S.
      • Kajiyama S.
      • Ito H.
      • Kaneko T.
      Usefulness of the "Non-Slip Element" Percutaneous Transluminal Angioplasty Balloon in the Treatment of Femoropopliteal Arterial Lesions.
      However, the impact of the guidewire route in chronic total occlusion (CTO) lesions on the dissection patterns after balloon angioplasty remains unclear.
      A few new high definition intravascular ultrasound (IVUS) systems in which the catheter can be pulled back automatically have recently become available. Using these systems, the morphology of diseased vessels can be evaluated precisely, and location mismatch can be reduced, resulting in improvement of the quality of retrospective analyses.
      • Saito Y.
      • Kobayashi Y.
      • Fujii K.
      • Sonoda S.
      • Tsujita K.
      • Hibi K.
      • et al.
      Clinical expert consensus document on standards for measurements and assessment of intravascular ultrasound from the Japanese Association of Cardiovascular Intervention and Therapeutics.
      However, data for the dissection patterns assessed by IVUS are scarce in the endovascular therapy (EVT) field.
      The aim of this study was to determine the impact of the guidewire route on severe dissection after balloon angioplasty for femoropopliteal CTO lesions using a new IVUS assessed dissection morphology classification scheme corresponding to a conventional angiographic classification scheme.

      Materials and methods

      Study samples and study protocol

      Consecutive limbs with femoropopliteal lesions (n = 261) treated endovascularly between May 2018 and December 2019 at the study institute were identified, 60 of which had de novo CTO lesions. Excluding limbs that received treatment for non-stenting zones such as the common femoral artery and P2 and P3 segments, 21 limbs (21 lesions, 19 patients) for which IVUS images had been obtained both after guidewire passage and after balloon angioplasty were used for analysis. The IVUS images after guidewire passage and after balloon angioplasty were evaluated at 1 cm intervals. Images were excluded in which the guidewire was passed through the subintimal or intramedial space (six cross sectional images), leaving a total of 219 cross sectional images. The images were divided into two groups by the guidewire route: those in which the guidewire passed through the inner half of the luminal radius (central wiring group, 139 cross sectional images) and those in which the guidewire passed through the outer half of the luminal radius (eccentric wiring group, 80 cross sectional images).
      This study complied with the Declaration of Helsinki for investigation in human beings and was conducted with the approval of the institutional ethics committee, and informed consent was obtained from all enrolled study patients.

      Interventional procedure

      All patients were pre-treated with dual antiplatelet therapy with aspirin (100 mg daily), clopidogrel (75 mg daily), or cilostazol (200 mg daily). Patients receiving an anticoagulant (warfarin, dabigatran, rivaroxaban, apixaban, or edoxaban) were given single antiplatelet therapy with one of the above mentioned antiplatelet agents.
      Arterial access was established in the contralateral or ipsilateral common femoral artery by placing a 6 F sheath (Destination; Terumo, Tokyo, Japan or Parent Plus, Medikit, Tokyo, Japan). After inserting the guiding sheath, 5 000 units of heparin was injected via the guiding sheath, and 2 000 units of heparin was routinely added on an hourly basis. In all cases, a 0.014 inch guidewire was chosen and advanced through the CTO lesions using an intraplaque wiring strategy. When the guidewire could not be passed through the CTO lesion under angiographic guidance, it was advanced under IVUS or duplex ultrasound guidance. IVUS guidance was performed by the parallel wiring technique in which the second guidewire is advanced under navigation from the first inserted guidewire.
      • Galassi A.R.
      • Sumitsuji S.
      • Boukhris M.
      • Brilakis E.S.
      • Di Mario C.
      • Garbo R.
      • et al.
      Utility of Intravascular Ultrasound in Percutaneous Revascularization of Chronic Total Occlusions: An Overview.
      Basically, in all the cases in which the guidewire passed through the subintimal or intramedial space, an attempt was made to re-cross the guidewire through the intraplaque space. After guidewire passage, high definition IVUS (Alta View; Terumo or OptiCross; Boston Scientific, Maple Grove, MN, USA) was performed to evaluate the morphology of the diseased vessel and to assess the guidewire route. When the IVUS catheter could not be passed through the CTO lesion, balloon dilatation using a 1.5 mm balloon catheter was performed to enable passage of the IVUS catheter. After checking the guidewire route and vessel morphology through the CTO lumen using IVUS, balloon angioplasty was performed. The maximum diameter of the balloon catheter was determined by reference to the inner cavity of the edges of the target lesion using IVUS measurement. A maximum sized balloon catheter was dilated for at least three minutes at the diseased lesion. The adjunctive use of a scoring balloon catheter was at the operator’s discretion. The diameter of the scoring balloon catheter was selected as a diameter that was smaller than the maximum sized balloon catheter, and the scoring balloon catheter was used before using the maximum sized balloon catheter. The scoring balloon was dilated multiple times through the whole of the lesion for the purpose of lesion preparation.
      All cases were treated using a primary drug coated balloon (IN.PACT Admiral; Medtronic, Dublin, Ireland) angioplasty and provisional stent implantation strategy. The stents used included a bare nitinol stent (S.M.A.R.T. Control: Cordis, Dublin, OH or INNOVA; Boston Scientific) and a drug eluting stent (Eluvia; Boston Scientific). Stent implantation was performed only in lesions with flow limiting dissection angiographically at the operator’s discretion.

      Definitions and data collection

      The guidewire route based on IVUS assessment was defined as either guidewire passage through the inner half of the luminal radius (central wiring) or through the outer half of the luminal radius (eccentric wiring) (Fig. 1). Morphology after balloon angioplasty was classified using an IVUS classification scheme for coronary balloon angioplasty proposed by Honye et al. as follows: Type A, a linear, partial tear of the plaque from the lumen to the media; Type B, a tear of the plaque that extends to the media; Type C, a dissection behind the plaque that subtends an arc of up to < 180° around the circumference; Type D, an extensive dissection with an arc of > 180° around the circumference; Type E1, concentric plaque without a tear or dissection; and Type E2, as in E1 but eccentric plaque (Fig. 2).
      • Honye J.
      • Mahon D.J.
      • Jain A.
      • White C.J.
      • Ramee S.R.
      • Wallis J.B.
      • et al.
      Morphological effects of coronary balloon angioplasty in vivo assessed by intravascular ultrasound imaging.
      Severe dissection was defined as Type C or greater in the National Heart, Lung and Blood Institute’s classification according to the angiographic appearance.
      • Fujihara M.
      • Takahara M.
      • Sasaki S.
      • Nanto K.
      • Utsunomiya M.
      • Iida O.
      • et al.
      Angiographic dissection patterns and patency outcomes after balloon angioplasty for superficial femoral artery disease.
      ,
      • Rogers J.H.
      • Lasala J.M.
      Coronary artery dissection and perforation complicating percutaneous coronary intervention.
      When biplane angiography was performed, the more severe dissection pattern between the two angiograms was used. Fig. S1 shows a correspondence figure between the angiograms and the IVUS images of a representative case.
      Figure 1
      Figure 1(A) Definition of guidewire routes during recanalisation of occlusive femoropopliteal lesions and intravascular ultrasound images for (B) central and (C) eccentric wiring routes.
      Figure 2
      Figure 2Dissection morphology patterns after balloon angioplasty of total occlusive arterial lesions according to intravascular ultrasound (IVUS) assessed lesion types A – E2. This scheme was modified from the IVUS classification scheme for coronary balloon angioplasty proposed by Honye et al.
      • Honye J.
      • Mahon D.J.
      • Jain A.
      • White C.J.
      • Ramee S.R.
      • Wallis J.B.
      • et al.
      Morphological effects of coronary balloon angioplasty in vivo assessed by intravascular ultrasound imaging.
      As a qualitative analysis, plaque morphology of the diseased vessel was classified into four types: soft, fibrous, calcified, and mixed.
      • Saito Y.
      • Kobayashi Y.
      • Fujii K.
      • Sonoda S.
      • Tsujita K.
      • Hibi K.
      • et al.
      Clinical expert consensus document on standards for measurements and assessment of intravascular ultrasound from the Japanese Association of Cardiovascular Intervention and Therapeutics.
      As a quantitative analysis, the external elastic membrane (EEM) area was measured in each cross sectional image. The ratio of the cross sectional image of the balloon catheter to the vessel size (B/V ratio) was calculated; the cross sectional image of the balloon catheter dilated at the nominal pressure was divided by the EEM area. Angiography based vessel characteristics were defined according to consensus definitions from the Peripheral Academic Research Consortium.
      • Patel M.R.
      • Conte M.S.
      • Cutlip D.E.
      • Dib N.
      • Geraghty P.
      • Gray W.
      • et al.
      Evaluation and treatment of patients with lower extremity peripheral artery disease: consensus definitions from Peripheral Academic Research Consortium (PARC).
      A full coverage balloon was defined as a balloon with a length greater than the CTO length. The scoring balloons used were NSE PTA (Nipro, Osaka, Japan) and Peripheral Cutting Balloon (Boston Scientific). Laboratory data including estimated glomerular filtration rate and lipid profile collected at the time of the procedure.
      The guidewire routes and dissection patterns were sorted on the basis of an independent view and agreement of two experienced cardiologists (T.S. and Y.S.) who were blinded to the clinical and procedural data. In the case of disagreement, the evaluation of a third cardiologist (K.M.) was obtained.

      Statistical analysis

      Continuous, normally distributed data were expressed as means ± standard deviation, and skewed data as medians and the first and third quartiles. For continuous data, the groups were compared using the t test or Wilcoxon’s rank sum test based on the distribution. Categorical variables were compared using the chi square test or Fisher’s exact test as appropriate. To evaluate the correlation between results of angiographic and IVUS analyses, the proportions of angiographically severe dissection were compared between lesions with Types D – E2 and Types A – C dissection patterns assessed by IVUS. This is based on a hypothesis that the Type D dissection pattern, in which the dissection extends with an arc of > 180° around the circumference, might be correlated with angiographically severe dissection. Multivariable logistic regression analysis was performed to identify independent risk factors for severe dissection. Variables for multivariable analyses were selected if they were empirically known to have an influence on severe dissection. Values are expressed as numbers (%) unless otherwise specified. Independent variables are expressed as odds ratios (OR) with 95% confidence intervals (CI). JMP 9 (SAS Institute Inc., Cary, NC, USA) was used for all statistical calculations.

      Results

      Baseline characteristics

      Table 1 shows the baseline characteristics of the patients. Central wiring was achieved in an average of 69.6 ± 28.0% of the CTO length from per limb analysis. Table 2 shows the baseline angiographic and procedural characteristics of the patients.
      Table 1Baseline characteristics of 21 femoropopliteal chronic total occlusion lesions in 19 patients
      Limbs (n = 21)
      Age – y75.2 ± 9.2
      Male14 (66.7)
      Rutherford classification
       10 (0.0)
       26 (28.6)
       310 (47.6)
       40 (0.0)
       54 (19.0)
       61 (4.8)
      Critical limb ischaemia5 (23.8)
      ABI pre0.42 ± 0.25
      ABI post0.73 ± 0.11
      Ambulatory20 (95.2)
      BMI – kg/m222.3 ± 2.6
      Diabetes mellitus13 (61.9)
      Hyperlipidaemia9 (42.9)
      Hypertension17 (81.0)
      Smoking history14 (66.7)
      Haemodialysis0 (0.0)
      Coronary artery disease4 (19.0)
      Old myocardial infarction1 (4.8)
      COPD2 (9.5)
      eGFR – mL/min/1.73m264.2 ± 18.6
      LDL-cholesterol – mg/dL93.1 ± 25.9
      HDL-cholesterol – mg/dL51.3 ± 17.6
      Triglycerides – mg/dL113.0 ± 44.1
      Aspirin14 (66.7)
      Thienopyridine19 (90.5)
      Cilostazol7 (33.3)
      Anticoagulant4 (19.0)
      Statin11 (52.4)
      Data are presented as n (%) or mean ± standard deviation. ABI = ankle brachial pressure index; BMI = body mass index; COPD = chronic obstructive pulmonary disease; eGFR = estimated glomerular filtration rate; LDL = low density lipoprotein; HDL = high density lipoprotein.
      Table 2Baseline angiographic and procedural characteristics of 21 femoropopliteal chronic total occlusion lesions
      Limbs (n = 21)
      TASC classification
       A3 (14.2)
       B6 (28.6)
       C6 (28.6)
       D6 (28.6)
      PACSS grade
       015 (71.4)
       14 (19.0)
       20 (0.0)
       32 (9.5)
       40 (0.0)
      Reference vessel diameter – mm4.7 ± 0.76
      Lesion length – cm20.9 (11.4–27.9)
      CTO length – cm10.3 (31.6–20.5)
      Below knee runoff
       03 (14.2)
       12 (9.5)
       213 (61.9)
       33 (14.2)
      Post MLD – mm2.9 ± 0.78
      Post %DS – %32.4 ± 23.4
      Approach side
       Ipsilateral approach12 (57.1)
       Contralateral approach9 (42.9)
       Bidirectional approach1 (4.8)
      Imaging guidance
       Angio10 (47.6)
       Duplex10 (47.6)
       IVUS1 (4.8)
      Biplane angiography16 (69.6)
      Balloon diameter – mm4.38 ± 0.59
      Balloon length – cm16.7 ± 8.7
      Full coverage balloon20 (95.2)
      Scoring balloon15 (65.2)
      Stent implantation7 (33.3)
      Full cover stent1 (4.8)
      Spot stent6 (28.6)
      Implanted stent type
       Bare nitinol stent3 (14.3)
       Drug eluting stent4 (19.0)
      Data are presented as n (%), mean ± standard deviation or median (interquartile range). CTO = chronic total occlusion; %DS = percent diameter stenosis; IVUS = intravascular ultrasound; MLD = minimum lumen diameter; PACSS = Peripheral Arterial Calcification Scoring System; TASC = TransAtlantic Inter-Society Consensus.

      IVUS analysis

      The proportion of angiographically severe dissections in the IVUS assessed dissection morphology patterns is shown in Fig. 3. Among the IVUS assessed dissection morphology patterns, lesions with Types D – E2 were more frequently correlated with angiographically severe dissection than were those with Types A – C (57.5% vs. 13.7%, p < .001).
      Figure 3
      Figure 3Proportion of angiographically severe dissections in intravascular ultrasound (IVUS) assessed dissection morphology patterns (see ) in 219 cross sectional IVUS images. The angiographic dissection patterns were classified A – F according to NHLBI classification or “None” if no angiographic dissection was detected. Type C or greater in the National Heart, Lung, and Blood Institute (NHLBI) classification was defined as angiographically severe dissection. Lesions with IVUS assessed Types D – E2 were more frequently correlated with angiographically severe dissection than were those with IVUS assessed Types A – C (57.5% vs. 13.7%, p < .001).
      The proportion of lesions with Type D – E2 dissection patterns assessed by IVUS was greater in the eccentric wiring group than in the central wiring group (58.8% vs. 23.7%, p < .001).
      Table 3 shows Type D – E2 dissection pattern predictive factors assessed by IVUS. Multivariable analysis showed that soft plaque was a predictive factor for severe dissection and that central wiring was a protective factor against Type D – E2 dissection patterns assessed by IVUS after balloon angioplasty in femoropopliteal CTO lesions.
      Table 3Univariable and multivariable analyses for predictive factors of severe dissection based on intravascular ultrasound findings obtained from 219 cross sectional images of 21 femoropopliteal chronic total occlusion lesions in 19 patients
      Univariable analysisMultivariable analysis
      Non-severe dissection (n = 139)Severe dissection (n = 80)p valueOR (95% CI)p value
      Central wiring106 (76.3)33 (41.3)<.0010.27 (0.14–0.49)<.001
      Plaque morphology<.001
      Soft plaque57 (41.0)57 (71.3)2.14 (1.007–4.72).048
      Fibrous plaque28 (20.1)7 (8.8)0.64 (0.21–1.84).41
      Calcified plaque13 (9.4)3 (3.8)0.62 (0.12–2.43).51
      Mixed plaque41 (29.5)13 (16.3)
      Balloon diameter4.0 (4.0–5.0)4.0 (4.0–5.0).54
      Balloon/vessel ratio0.60 ± 0.270.54 ± 0.26.12
      Scoring balloon68 (48.9)34 (42.5).40
      Long balloon123 (88.5)69 (86.3).67
      Data are presented as n (%), mean ± standard deviation or median (interquartile range). CI = confidence interval; EEM = external elastic membrane; IVUS = intravascular ultrasound; OR = odds ratio.

      Discussion

      The aim of this study was to determine the factors associated with severe dissection in femoropopliteal CTO lesions after balloon angioplasty by evaluating the correlation between results of angiographic and IVUS analyses. IVUS assessed Type D or greater was correlated with angiographically severe dissection. Central wiring may be useful for preventing severe dissection.
      In the endovascular therapy field, angiographically severe dissection is known to be correlated with restenosis after plain balloon angioplasty.
      • Fujihara M.
      • Takahara M.
      • Sasaki S.
      • Nanto K.
      • Utsunomiya M.
      • Iida O.
      • et al.
      Angiographic dissection patterns and patency outcomes after balloon angioplasty for superficial femoral artery disease.
      IVUS analysis can show the vessel wall in a 360° view and thus potentially reveal more precise dissection morphology than can angiographic analysis; however, data for dissection patterns assessed by IVUS are scarce in the EVT field. There are no available data about long term patency in this study population; however, Type D – E2 dissection patterns assessed by IVUS might also be correlated with restenosis, and further investigation is needed to clarify this.
      Less severe dissection after central wiring may be the result of plaque distribution around the guidewire being greater even in central wiring than in eccentric wiring. Methodologies of balloon angioplasty for preventing severe dissection have been shown in several reports;
      • Tan M.
      • Urasawa K.
      • Koshida R.
      • Haraguchi T.
      • Kitani S.
      • Igarashi Y.
      • et al.
      Comparison of angiographic dissection patterns caused by long vs short balloons during balloon angioplasty of chronic femoropopliteal occlusions.
      • Horie K.
      • Tanaka A.
      • Taguri M.
      • Kato S.
      • Inoue N.
      Impact of prolonged inflation times during plain balloon angioplasty on angiographic dissection in femoropopliteal lesions.
      • Horie K.
      • Tanaka A.
      • Taguri M.
      • Inoue N.
      Impact of scoring balloons on percutaneous transluminal angioplasty outcomes in femoropopliteal lesions.
      • Karashima E.
      • Yoda S.
      • Yasuda S.
      • Kajiyama S.
      • Ito H.
      • Kaneko T.
      Usefulness of the "Non-Slip Element" Percutaneous Transluminal Angioplasty Balloon in the Treatment of Femoropopliteal Arterial Lesions.
      however, from multivariable analysis in the present study, central wiring was shown to be protective, but the impact of the balloon dilatation methodology was not proved. This could be because of the design of this study in which cross sectional images of IVUS were analysed at 1 cm intervals, the high rate of full coverage balloon use (in 20/21 cases), and the long duration of inflation (dilation for at least three minutes using a maximum sized balloon catheter in all cases).
      The concept of guidewire routes inside the plaque, central, and eccentric wiring routes, is uncommon; however, the present authors believe that consideration should be given not only to intraplaque wiring but also central wiring for preventing severe dissection after balloon angioplasty. However, especially in lesions containing thrombus material, in which differentiation of the thrombus material from pure lipid plaque is difficult by IVUS evaluation, stent implantation is potentially inevitable. Also, especially in eccentric calcified lesions, the guidewire cannot be crossed centrally no matter how this is attempted. This study was based on analysis of all embracing IVUS images and included lesions in which the guidewire route is irrelevant. Whether central wiring should be attempted in all lesions remains unclear, and further investigation is needed.
      The guidewire was crossed through the non-intraplaque lumen in only six of the 225 cross sectional images evaluated in this study. It is considered that the high rate of intraplaque wiring resulted from the imaging guidance strategy. Among 11 cases (52.4%) in which the guidewire could not be crossed under angiographic guidance, duplex ultrasound guidance was performed in 10 cases (47.6%) and IVUS guidance in one case (4.8%). Duplex ultrasound guidance potentially enables passage of the guidewire not only through the intraplaque lumen but also the central route in a non-invasive way. The effect of IVUS guidance cannot be discussed as this was performed in only one case in this study.

      Limitations

      There are several limitations to this study. First, this was a retrospective single centre study using non-randomised data. Second, the concept of guidewire route, central wiring, and eccentric wiring, is uncommon. The subintimal and intramedial routes were excluded from analysis because the number of cases in which these routes were passed was very small and there is the possibility of severe dissection occurring after balloon angioplasty because of the intervening membrane. Third, this study was not conducted by per lesion analysis but by per segment analysis because the lesions contained both central and eccentric crossing segments. IVUS assessment of dissection patterns lacks longitudinal analysis, and the correlation between the wiring route and the dissection pattern might be potentially limited. Fourth, because the number of patients was small, this study can be regarded only as a hypothesis generating study.

      Conclusion

      Lesions with Type D – E2 dissection patterns assessed by IVUS were correlated with angiographically severe dissection. Central wiring may be useful for preventing severe dissection after balloon angioplasty for femoropopliteal CTO lesions.

      Acknowledgements

      The authors are grateful to sonographers at Kurashiki Central Hospital for their technical cooperation. We also thank Miho Kobayashi for her writing assistance and Makiko Kanaike, Yoshimi Akashi, and Takako Yukiyoshi for their secretarial assistance with the manuscript.

      Conflict of interest

      None.

      Funding

      None.

      Appendix A. Supplementary data

      The following are the Supplementary data to this article:
      • Multimedia component 1

        A correspondence figure between the angiograms and the intravascular ultrasound images of a representative case. (A) Before and (B) after balloon angioplasty. IVUS = intravascular ultrasound; LAO = left anterior oblique view; AP = anteroposterior view.

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