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Patient initials or identifier number
Relevant clinical history and physical exam
A 45 year-old man was diagnosed with right popliteal artery entrapment syndrome by acute limb ischemia. A femoro-posterior tibial artery bypass and release of the entrapment were performed. He developed a right, intermittent claudication one year after the surgery due to noncompliance with his antiplatelet treatment. He was transferred to our institution for the purpose of endovascular treatment, as he refused re-surgery.
Relevant test results prior to catheterization
Ankle Brachial Pressure Index: right 0.61/ left 1.25
CT: Both the right popliteal bypass graft and the native popliteal artery were occluded
The latter was also shrunken
A pseudoaneurysm suspected on the right common femoral artery
Relevant catheterization findings
The right native popliteal artery and the bypass graft were occluded with rich collateral and had no stump. A posterior tibial artery suitable for distal puncture was available.
We chose the contralateral approach due to the pseudoaneurysm on the right femoral artery. The angiography showed no stump of the native artery and bypass graft. The intravascular ultrasound from the collateral artery indicated the entry of the bypass graft, not the native artery. First, we advanced the stiff wire to the distal anastomosis site, then punctured the posterior tibial artery and inserted the micro catheter in order to use a bidirectional approach. The retrograde wire crossed the occluded bypass graft by the kissing wire technique, and wire externalization was established. After thrombus aspiration and dilation via a 1.5 mm balloon, the intravascular ultrasound eventually delineated the distal anastomosis site that indicated the exit of occluded native artery. Thereafter, the retrograde stiff wire punctured the exit of the occluded native artery. The middle of the occluded native artery was so hard, due to fibrous plaque, that we used the knuckle wire technique in order to not exit the vessel. Finally, the retrograde wire re-established the wire externalization by a rendezvous technique. We created dilation from the posterior tibial artery to the popliteal artery with a 1.5 mm to 4.0 mm balloon. The final blood flow of the native artery was superior to that of the bypass graft; and the pulse of the posterior tibial artery reversed; this indicated that the bypass graft flow might not affect the patency of the native artery, and occluded in the near future.
A popliteal artery entrapment syndrome and subsequent bypass surgery could cause severe, hard, fibrous occlusion of the native popliteal artery. Endovascular therapy that opens the native vessel is important to keep patency.
It was impossible to advance the antegrade wire, as the entry of the native artery was not found by angiography or intravascular ultrasound imaging, making retrograde approach mandatory in our case. However, retrograde angiography also indicated that there was no entry point. Therefore, we firstly opened the bypass graft to monitor the distal anastomosis site, and to guarantee that there would be straight flow in the event that the native vessel could not be opened.