Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 63 year-old diabetes and heart failure with impaired LV function patient suffered from severe left leg pain and had an unhealed ulcerative wound at his left heel. The symptoms turned worse after he received endovascular treatment in another hospital 3 months prior to consulting with me. During his previous endovascular treatment, the lesions of his left superfical femoral artery and anterior tibial artery were treated with the antegrade approach from his left superficial femoral artery.
Relevant test results prior to catheterization
Old MI with CAD-3VD.
Impaired LV function with general hypokinesia and LVEF 21%.
Relevant catheterization findings
I performed the crossover approach from his right common femoral artery. The angiography showed left external iliac artery diffuse 70-90% stenosis, left proximal superficial femoral artery 70-80% stenosis at the previous puncture site, left superficial femoral artery shaft diffuse minimal in-stent re stenosis, left anterior tibial artery distal diffuse stenosis with good vessel run-off, left peroneal artery total occlusion, and left posterior tibial artery chronic total occlusion with collateral.
From right common femoral artery crossover approach with the 7 french shuttle sheath, I performed balloon dilatation and treated his left external iliac artery with the undersized 5.0 x 40 mm balloon. After balloon dilatation, the patient complained of severe abdominal and groin pain and the angiography revealed acute arterial occlusion due to severe dissection. I deployed the 7.0 x 60 mm self-expanding stent to seal the entry tear and prevented pseudoaneurysm, retroperitoneal hematoma and vessel perforation. After stenting, the vessel showed very good vessel runoff and the distal iliac artery had residual 20-30% stenosis. Because I needed to treat the superficial femoral artery and the lesions below the knee, I decided not to stent his distal iliac artery to reduce the rate of stent migration. If this was to happen, it would be very dangerous because it was close to the hip joint. We treated superficial femoral artery and also stented with the metallic stent. When treating the wound of the Rutherford classification stage 6, the single stenotic tibial vessel runoff might not be enough to heal it well. From the angiosome concept, I needed to treat his posterior tibial artery because the calcaneal branch supplies the heel. Due to these reasons, I re canalized the vessel with a 0.014 wire and treated the vessel with the 2.5 x 40 mm balloon and was able to achieve very good vessel runoff.
The SFA antegrade approach for treating the multilevel lesions of peripheral artery disease always runs the risk of missing lesions. Moreover, the vessel access increases the chances of making the puncture site become stenotic. Despite this, the iatrogenic iliac artery dissection can be resolved easily by the metallic stent. We need to observe any of the patient's peri-operational symptoms carefully. Furthermore, the angiosome concept is very useful for treating multilevel and multi vessel peripheral artery disease especially in a patient with heart failure and renal insufficiency. For this kind of patient, we need to try our best to shorten the operation time and reduce the contrast amount.