Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 76 year-old woman had a medical history of chronic kidney disease, asthma, and old cerebrovascular accident. In history taking, she had a symptom of both resting leg pain for several months (Rutherford 4). There were no pulsations in both femoral and distal pulse points.
Relevant test results prior to catheterization
Lower extremities computed tomography (CT) angiography showed that from right external iliac artery (EIA) to common femoral artery (CFA) and left EIA was totally occluded. Ankle brachial index (ABI) 0.0/0.61 (right/left).
Relevant catheterization findings
By left brachial approach with a 6-Fr sheath, initial angiogram revealed that both external iliac arteries were occluded without visible proximal stump.
The ECG revealed ST Depression II/III AVF 2D ECHO revealed LAD tertiary akinetic moderate LV Systolic Dysfu We performed left CFA puncture under fluoroscopic guidance. From CFA subintimal angioplasty was performed using 0.014 in. G/W under micro-catheter forming a wire loop. When the guide-wire passed through CTO segment, IVUS images showed the location of G/W at subintimal space. After balloon angioplasty, left iliac artery was successfully re canalized with self-expandable stent implantation. Thereafter, attempt to re canalize right iliac artery was made using a 0.035 in. hydrophilic G/W under glide catheter in antegrade fashion. We need another access site for bi-directional approach, but there was no common femoral artery visualized. To overcome this problem, we performed distal SFA puncture with a micro puncture kit. After gently introduced 0.014 G/W through the distal part of occluded segments, reattempt to crack occluding plaque of the distal stump was made. Then rendezvous technique was performed and the guide-wire was able to be externalized. We performed balloon angioplasty and implanted self-expandable stent from right iliac artery to proximal part of a common femoral artery. After complete recanalization of bi-iliac arteries, final angiography revealed that there was no residual stenosis without dissection action. HB 13GM /DL CREATININE 0.90MG SERUM K 4.2 SODIUM 136 meq Ultrasound Abdomen Revealed Large Suprarenal Mass CECT Abdomen Revealed Mass 9.0 – 3.6 x 3.6, Large lobulated, roughly oval,Mixed soft tissue density mass.
Above upper pole of Left Kidney.Portal Venous Phase: Enhancement up to 176 HU, Delayed Phase: Washout up to 76 H suggestive of pheochromocytoma.
For the treatment of multilevel total occlusions, multiple vascular access can be helpful and improve the technical success rate. In the treatment of long iliac artery occlusion, subinimal angioplasty is an effective technique.