Author + information
- Kazuya Shinji1
Patient initials or identifier number
Relevant clinical history and physical exam
A 75 year-old man with a history of hypertension, hyperlipidemia,and tobacco use noted progressive bilateral calf discomfort during activity. Thesesymptoms slowly progressed, and they became so severe that he was unable to exercise.He discussed these symptoms with his primary care physician. His physiciandetected diminished pulses distally.
Relevant test results prior to catheterization
His resting ankle brachial index(ABI) was 0.56 on the right and 0.41 on the left.
Relevant catheterization findings
An Aortography was performed and it showed chronictotal occlusion (CTO) from right external iliac artery (EIA) to common femoral artery(CFA) and from left external iliac artery (EIA) to superficial femoral artery (SFA).The bilateral deep femoral artery (DFA) was contrasted.
The 1st EVT for CTO from right EIA to CFA.
A 6Fr Sheath less PV was inserted through the right popliteal artery and a 6Fr Sheath less PV was inserted through the left brachial artery, respectively. An antegrade wire was advanced into the distal true lumen. After that we inserted IVUS catheter .The IVUS image showed that wire was in the intra-plaque. Two SMART stents were implanted in the EIA. After that, A long ballooning at the CFA was performed.Final angiography showed the successful recanalization.
The 2nd EVT for CTO from left EIA to left SFA.
A 6Fr Sheathless PV was inserted through the left popliteal artery and a 6Fr Sheath less PV was inserted through the left brachial artery, respectively. Initially, we inserted two wires into the CTO lesion antegradely and retrogradely. However, both of the wires were into subintimal spaces and we could not track intimal plaque with IVUS guidance.A subintimal angioplasty at CFA poses the risk of occlusion of deep femoral artery(DFA). Therefore, we decided to puncture the DFA. Fortunately a wire was advanced into the proximal true lumen retrogradely through DFA. After that, IVUS catheter was inserted and it showed wire was in the intra plaque at CFA. A hemostasis at DFA puncture site was achieved with ballooning and tronbin. After that we crossed a wire into the SFA antegradely. We implanted SMART stents at EIA and SFA. A long ballooning at the CFA was performed.Final angiography showed the successful re canalization.
A 75 year-old man received EVT for bilateral liliofemoral long CTO using DFA puncture .A subintimal angioplasty at CFA poses the risk of occlusion of deep femoral artery(DFA).So, we decided to puncture the DFA. Puncturing on the DFA could be a risk of getting serious injury on the site, however, it could be a great opportunity for CTO treatment due to an extra back up. Restudy angiogram 6 months later showed excellent flow of bilateral iliofemoral artery.