Author + information
- Masao Yamasaki1
Patient initials or identifier number
Relevant clinical history and physical exam
A 77 years-old male was admitted to our hospital with left leg pain and numbness at rest for several days. He had suffered from intermittent claudication during 50 m walking for 2 months. He has also hypertension, dyslipidemia and smoking history. His left lower leg was pale and neither anterior tibial artery nor posterior tibial artery was palpable.
Relevant test results prior to catheterization
Some laboratory data including WBC (9800/ul), CK (418 IU/L) and D-dimer (4.0 ug/ml) were elevated. Left ABI was not measurable (right was 1.06). Contrast CT showed complete vessel occlusion from left common iliac artery (CIA) to left common femoral artery (CFA), and also at left superficial femoral artery (SFA). Left deep femoral artery (DFA), popliteal artery (POP), and lower limb arteries were patent.
Relevant catheterization findings
We immediately performed thrombectomy using 6Fr Fogarty catheter from left CIA to left CFA by cutting open the left CFA. In addition to thrombectomy, balloon angioplasty was performed at left CIA. After these procedures, his left leg got warm and ABI increased up to 0.38.
The additional endovascular treatment (EVT) to left SFA chronic total occlusion (CTO) lesion was performed contralaterally 4 days later. At first, we confirmed good flow from left CIA to left DFA (left SFA was occluded at the bifurcation site with DFA), and then introduced 6F sheath less PV guide catheter to the left CFA. Naveed 4 (0.014 inch, 15 g) guide wire successfully passed beyond left POP antegradely by IVUS support. IVUS confirmed that the wire passed completely through the intra plaque or intra lumen. Pre dilatation with Coyote 4.0/220 mm and Sterling 6.0/220 mm balloon for all CTO lesions was performed, followed by stenting from the SFA ostium using Innova 7.0/180 mm self-expanding stent. Post dilatation was also added using Sterling 6.0/220 mm balloon, achieving excellent distal run off down to the foot. Left ABI increased up to 0.90, and the patient discharged 3 days later with no symptoms.
We performed hybrid therapy (surgical treatment using Fogarty catheter to iliac thrombotic lesion and subsequent EVT to SFA CTO) with surgeons for subacute peripheral artery occlusion in addition to CTO lesion, and succeeded in limb salvage. This treatment strategy may be safe and effective for some of emergent and complicated cases.