Angioscopy Using CO₂ for Femoropopliteal Occlusive Disease

A man in his 60 s with a history of severe renal dysfunction (estimated glomerular filtration rate 19 mL/min/1.73 m²), hypertension, and diabetes mellitus presented with gangrene in his right 1st and 5th toes. We performed endovascular therapy (EVT) for the totally occlusive lesion in the superior femoral artery (SFA) using carbon dioxide (CO₂) angiography (Figure A). A 6-French guiding sheath was inserted into the right common femoral artery, but because we could not pass the 0.014-inch guidewire through the proximal cap of the femoropopliteal lesion, we examined the cap’s morphology using high-resolution angioscopy (Zemporshe^TM angioscopic catheter; OVALIS, Osaka, Japan) with CO₂.¹ We blocked the blood flow by manually injecting ≈20 mL of CO₂ and compressed the ipsilateral femoral artery to keep the gas localized (Figure B). This technique provided a clear view of the peripheral arteries for ≈15 s and revealed a small pouch of the proximal cap and the vascular lumen (Figure C; Supplementary Movie). Subsequently, a stiff 0.014-inch guidewire penetrated the proximal cap and crossed the SFA occlusive lesion (Figure D). Finally, EVT was successfully performed using a 6.0-mm drug-coated balloon (Figure E–G).

Figure.

(A) Control CO₂ angiography; (B,C) small pouch of the proximal cap (arrow), the ostium of a branch artery (arrowhead), and the vascular lumen; (D) stiff 0.014-inch guidewire penetrates the proximal cap and crosses the occlusive lesion; (E) CO₂ angiography after balloon angioplasty; (F) drug-coated balloon; (G) final angiogram.

Injection of CO₂ completely shut off blood flow, and then angioscopy could depict a clear image of the peripheral arteries during the EVT. This case suggests the possibility of CO₂ as a novel agent for angioscopy in EVT for femoropopliteal lesions.

This procedure followed the “Declaration of Helsinki” and ethical standards of the responsible committee on human experimentation (20220011C).

Disclosures

H.T. is a member of Circulation Journal’s Editorial Team.

Supplementary Files

Supplementary Movie. Angioscopy using CO₂.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-23-0173

Reference

• 1.   Mitsutake Y, Yano H, Ishihara T, Matsuoka H, Ueda Y, Ueno T. Consensus document on the standard of coronary angioscopy examination and assessment from the Japanese Association of Cardiovascular Intervention and Therapeutics. Cardiovasc Interv Ther 2022; 37: 35–39.