Author + information
- Naoki Hayakawa1
Patient initials or identifier number
Relevant clinical history and physical exam
A 62 years old-male was referred for rest pain and pale of his right lower limbs. He felt rest pain of his right leg from two days ago. His peripheral arteries were not palpable from right popliteal artery. So he was introduced to our vascular surgery department.
Relevant test results prior to catheterization
ECG showed sinus rhythm and UCG showed there were no thrombus in the left atrium. The enhanced CT showed total occlusion from his right popliteal artery. And there were atheroscleroic change in his BTK lesions. So it seemed to be acute occlusion of his right popliteal artery based on ASO. At first vascular surgeon tried to treat by Fogaty catheter. They could remove the thrombus, however his symptom got worse maybe because they didn't treat BTK lesion. So we decided to treat him by EVT.
Relevant catheterization findings
We started from left femoral approach, and control angiography showed a total occlusion from his right SFA ostium. Using Command wire with IVUScatheter, we could pass the lesion from SFA to PTA. IVUS showed a large amount of thrombus in his SFA to popliteal artery. After the aspiration we performed ballooning from BTK to SFA. Finally,we deployed two SMART stent in his SFA, and performed catheter thrombolysis. 2 days after the angiography showed the thrombus was almost disappeared.
His right leg was salvaged. However, 3 months after, large wound of his right leg was appeared and not healed, so we decided to perform the EVT for BTK lesions. We performed ipsilateral antegrade approach, and control angiography showed total occlusion of ATA and PTA. At first we tried to PTA CTO. We could choice PTA by Chevalier floppy wire with Prominent micro catheter. However, antegrade wire was advanced into subintimal space. We started retrograde approach, performing PTA puncture. After that we could achieve wire rendez-vous technique and could pass the lesion. We could get sufficient antegrade flow in his PTA. Next in the ATA, we suffered to advance the CTO lesion because the CTO was abrupt type from ostium. We used Astato XS9-12 with bending the tip and could penetrate. We advanced the antegrade wire with parallel wire technique but couldn’t reach the distal true lumen. So we perform the retrograde approach by trans-pedal approach from PTA to plantar artery to dorsal artery. We used the Chevalier floppy wire with Prominent BTA microcatheter and could reach the antegrade wire. Finally we could pass the lesion by kissing wire technique. We performed the long inflation by Cross perio 2.5/200 mm, we could get almost complete revascularization in his BTK. After the procedure, SPP was elevated dramatically.
Generally ALI should be treated by surgical treatment using Fogaty catheter. However, there are some cases when EVT is suitable due to including BTK lesions. Inaddition, we sometimes experience the case that is needed additional EVT for BTK and BTA lesion for CLI patient. In this case, we experienced almost complete revascularization for CLI patient after ALI. Additionally, most important thing is all procedure from ALI to CLI performed by only endovascular treatment.