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Patient initials or identifier number
Relevant clinical history and physical exam
A 94-year old Japanese female was referred to our hospital for treatment of skin ulcer on the right planta pedis. There was no abnormal physical finding in her chest and abdomen. However, pulseless ness on the right lower extremity below the common femoral artery was observed. Critical limb ischemia (Rutherford class 5) was highly suspected and we planned endovascular treatment (EVT) for her right leg.
Relevant test results prior to catheterization
Her ankle-brachial pressure index on the right side couldn't be measured. Limb ultrasonography showed total occlusion from common iliac artery (CIA) as far as distal end of superficial femoral artery (SFA).
Relevant catheterization findings
The diagnostic angiography with a left trans-brachial approach demonstrated total occlusion from just proximal to the right CIA.
A 6Fr Parent Plus guiding sheath was introduced to the terminal aorta. We successfully reached a guidewire to the intraluminal space of the common femoral artery (CFA). However, the SFA was totally occluded, and guide wire couldn’t be advanced to the distal end of the SFA. Therefore, we deployed three self-expandable stents in the iliac artery, and finished this session. We started the second session via left CFA. Initial angiography showed right iliac occlusion with massive thrombi. This time, we successfully penetrated the occluded SFA to the popliteal artery, and firstly deployed two self-expandable stents in the SFA. Next, we retrogradely inserted an 8Fr sheath via right CFA. Then, we delivered a 4.0 mm balloon catheter from the left CFA and inflated it at the same position as the tip of the 8Fr sheath to occlude the right external iliac artery. We crushed thrombi by 6.0 mm balloon catheter and aspirated the crushed thrombi using 8Fr sheath. Final angiography demonstrated disappearance of massive thrombi in the right iliac artery and good patency from aortic bifurcation to plantar artery.
Distal embolism can occasionally be critical when we treat a lesion with massive thrombi. We demonstrated herein a very simple but possessively useful embolic protection system. It may probably reduce medical costs and complexity of EVT procedures.