Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 73 years-old lady was presented to our hospital complaining of both lower limb resting pain associated with cyanosis and cold sensation. She is known to be diabetic and hypertensive on medical treatment with no history of smoking or alcohol intake, with past history of cholecystectomy 10 years ago.
Relevant test results prior to catheterization
Her laboratory finding was unremarkable. ECG showed atrial fibrillation and left ventricular hypertrophy strain pattern. Echocardiography showed normal left ventricular (LV) systolic function (ejection fraction, EF: 61%) with mild rheumatic mitral steno-insufficiency and mild aortic insufficiency. No regional wall motion abnormality (RWMAs) could be detected at rest.
Computed tomography (CT) scanning revealed occlusion of the distal abdominal aorta, bilateral iliac (including common, external, and internal iliac) arteries, and bilateral distal superficial femoral artery occlusion. (Figure 1)
Relevant catheterization findings
Immediate radial approach was planned for checking coronary angiography at first but brachial artery thrombosis was detected by upper limb angiography. Right (Rt) femoral approach was done and femoral angiography showed distal aorta and both iliac arteries occlusion with heavy thrombus burden extending to the superficial femoral artery (SFA), which in turn makes the aorto-iliac intervention is very risky and not feasible.
Optimal anticoagulation therapy was recommended for 4 months, after which intervention was planned in a 2 separate stages.
Percutaneous transluminal angioplasty (PTA) of the Rt iliofemoral artery through brachial approach through which angled then Stiff Terumo guidewires failed to pass intraluminally to the Rt iliac artery, so retrograde approach was decided.
Through micro-puncture to the distal SFA, 0.18 (V-18) guidewire was retrogradely advanced to Rt iliac artery subintimally under CXI support catheter.
This was followed by predilatation and stenting of the Rt iliac artery and distal SFA then postdiltation balloon was used for stent optimization.
A week later, PTA to the Lt iliac artery was done. Connect Flex 018 wire was passed from Lt femoral short sheath retrogradely through iliofemoral occlusion intraluminally, followed by balloon dilation.
Then a Terumo wire could pass from the contralateral Ansel check-flo guiding catheter to Lt SFA, followed by Lt femoral sheath removal during balloon angioplasty. This was followed by balloon dilation of the iliac, femoral and popliteal arteries by drug coated balloon. The following angiography showed more than 50% recoil with heavy organized thrombus in Lt iliac artery thus stenting of the Lt iliac artery was done followed by stent optimization by postdilatation balloon, with excellent distal flow angiographically and as shown by post intervention CT angiography.
Conservative management in the form of intense medical therapy may be a good option in patients with extensive thrombosis making immediate intervention risky and non-feasible especially in clinically non critical patient with increased surgical risk.