IVUS-guided wiring using the deep vein as a landmark (IDEAL) technique for treating chronic total occlusions in peripheral artery disease.

Background: Endovascular therapy (EVT) is a well-established revascularization strategy for patients with peripheral artery disease. However, achieving optimal wire crossing in complex chronic total occlusion lesions remains technically challenging. Intravascular ultrasound (IVUS)-guided wiring facilitates safer and more effective procedures. However, aligning IVUS findings with fluoroscopic imaging is challenging due to catheter rotation. We report a novel technique-termed the IDEAL technique-that leverages the deep vein as an anatomical landmark to correct IVUS rotational orientation.

Case presentation: A 76-year-old female presented with chronic limb-threatening ischemia in the right toe. Contrast-enhanced computed tomography revealed a chronic total occlusion in the right superficial femoral artery. EVT was performed via the right common femoral artery. IVUS revealed that the first guidewire had entered the subintimal space partway through its course. Using preprocedural computed tomography, the deep vein was identified and its clock-face position relative to the artery was determined. This anatomical landmark enabled correction of IVUS image rotation, allowing accurate re-direction of a second guidewire under fluoroscopic guidance, thereby successfully crossing into the intraplaque lumen.

Conclusions: The IDEAL technique quickly provides anatomical orientation by utilizing the deep vein as a landmark during IVUS-guided wiring-making it, quite literally, ideal.