Figura 1. Digital angiography: distal obstruction of the abdominal aorta with bilateral iliac axis i...

Figura 2. Post-dilation subintimal recanalization through the access. CART technique.

Figura 3. Self-expanding stent implantation and kissing technique.

Figura 4. Final angiography showing complete revascularization of the aortoiliac axis.

Figura 5. Follow-up CT angiography at 8 months.

We report the case of a patient with chronic intermittent claudication who experiences extensive bilateral aortoiliac occlusion. She has Leriche syndrome and an unfavorable arterial anatomy for surgical treatment. This type of lesion is classified as a TransAtlantic Inter-Society Consensus (TASC) II type D lesion. According to consensus guidelines, surgical revascularization is considered the first-line treatment, as it has shown optimal long-term outcomes with low restenosis rates. However, when peripheral arterial disease is associated with a porcelain aorta, the anatomical characteristics are unfavorable and require careful planning, considering endovascular treatment as a convenient alternative.

Clinical case

The case presented case is that of a 76-year-old woman. Her cardiovascular risk factors included hypertension, dyslipidemia, heavy smoking, and chronic obstructive pulmonary disease. She had no relevant known history of cardiovascular disease. She presented with severe intermittent claudication for over two years and rest pain (Fontaine III–Rutherford IV). On physical examination, both lower limbs had abolished bilateral femoral pulses and weak distal pulses. A CT angiography revealed severe arterial disease in the extensive aortoiliac area and a porcelain aorta.

An angiography with digital subtraction was performed via right humeral access, and it revealed severe disease at the distal abdominal aorta with obstruction extending into both common iliac arteries (Figure 1). The patient’s unfavorable characteristics influenced the choice of approach, the selection of materials, and procedure planning. After a multidisciplinary review, a choice was made for an endovascular approach using the controlled antegrade and retrograde subintimal tracking (CART) technique, which involves controlled antegrade and retrograde subintimal passage.

In the cath lab, operators achieved right humeral access and ultrasound-guided retrograde puncture of both common femoral arteries, placing 7-Fr hemostatic introducers. Attempts to recanalize the occlusion via transfemoral access were unsuccessful. Using the humeral access, a 6-Fr pigtail catheter was advanced under hydrophilic guidewire guidance into the subintimal space (Figure 2). Simultaneous balloon dilations at 6 atmospheres were performed to create a subintimal dissection and facilitate reentry into both iliac arteries. Extending the subintimal dissection beyond the occluded area was not necessary. Hydrophilic guidewires were then exchanged for Amplatz wires, providing better support, positioning, and navigation of the materials.

Self-expanding Epic™ Vascular stents were implanted in both iliac arteries, finalizing with the kissing stent technique (Figure 3). Femoral accesses were closed percutaneously using Proglide, and a final control angiography via humeral access showed proper stent implantation with no significant residual lesions along the aortoiliac axis (Figure 4).

The patient received 5000 IU of heparin and was discharged after two days of hospitalization. Procedure time was 50 minutes with a total of 200 mL of low-osmolar contrast.

Follow-up at 8 months showed the effectiveness of the technique, reflected in the resolution of symptoms (Figure 5).

Discussion

Leriche syndrome associated with a porcelain aorta is one of the most challenging scenarios in vascular disease. The severe calcification of the abdominal aorta, the extent of the occlusion, and the patient’s advanced age turned the conventional surgical approach into an unsafe alternative due to high surgical risk and unfavorable anatomical conditions. In this context, the chosen strategy was an advanced endovascular option: the CART technique, initially described in cases of chronic total coronary intervention and later adopted for peripheral disease. The technical challenges of the procedure began with the choice of access, which was crucial for the final success. Combined femoral and brachial approaches were used to achieve bidirectional access. During recanalization, extensive calcification hindered device advancement, thus requiring the use of specialized catheters and high-support guidewires. Successful crossing was achieved using this technique, which involved connecting the subintimal planes in both directions by inflating angioplasty balloons. Procedure completion with the kissing stent technique was essential to ensure symmetrical iliac bifurcation structure and optimize flow.

In the literature, the use of the CART strategy in aortoiliac occlusion is not widely reported; it is much more common in coronary arteries with chronic total occlusion. This case helps demonstrate its feasibility in more complex cases such as in the distal aorta and its iliac branches under extreme anatomical conditions. This experience highlights that the CART technique can be a valid and safe alternative in patients at high surgical risk or with anatomies unsuitable for conventional surgery, such as in the presence of a porcelain aorta, which complicates both arterial clamping during surgery and vascular graft suturing. This is in addition to the increased clinical risk due to comorbidities such as chronic obstructive pulmonary disease. The strengths of this approach include minimally invasive treatment, rapid recovery, and early hospital discharge, while its main limitations are longer fluoroscopy exposure time and the need for high technical expertise.

The patient was discharged on dual antiplatelet therapy (acetylsalicylic acid 100 mg and clopidogrel 75 mg) for six months, followed by long-term single antiplatelet therapy. Anticoagulation was considered unnecessary due to the endovascular nature of the treatment and the absence of prothrombotic conditions.

Conclusion

The implementation of the CART technique requires experience, precise planning, and knowledge of the materials. In this case, the strategy proved effective and safe. The endovascular resolution achieved clinical improvement, restoring flow and perfusion in the aortoiliac area without complications and with a short hospitalization period.

Finally, we consider that endovascular intervention should always be used as an alternative for patients who are not candidates for surgery.

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