Author + information
- Tetsuya Nomura1
Patient initials or identifier number
Relevant clinical history and physical exam
An 85 year-old Japanese female with hypertension referred to our hospital for the treatment of critical limb ischemia (CLI) (Rutherford class 5) on the right lower extremity. Her body mass index was 18.0 kg/m2. There was no abnormal physical finding in chest and abdomen. However, pulselessness on both sides below the common femoral arteries was observed. Moreover, she had skin ulcerations at the right knee and heel, and necrosis of the right first toe.
Relevant test results prior to catheterization
Her ankle-brachial pressure index (ABI) was very low at both sides (right: 0.39, left: 0.30), and computed tomography (CT) showed bilateral aorto-iliac occlusion with severe calcification. Laboratory examination showed normocytic slight anemia, normal renal parameters, and slightly elevated CRP.
Relevant catheterization findings
We established bidirectional vascular access sites from the left brachial and bilateral femoral arteries.
We found aorto-iliac total occlusion with dense calcification just as shown in CT angiography.
At first, we retrogradely passed a 0.014-inch guidewire through the calcified lesion at the right common iliac artery (CIA). We inflated a 3.0 mm balloon catheter at the CIA and advanced a 6Fr guiding catheter near the terminal aorta. We tried further advancement of a guide wire, but we could not make it because of the dense calcification. Therefore, we switched to antegrade wiring. We could successfully penetrate the proximal hard cap with an Astato 9-40 guide wire. However, the micro catheter could not follow the guide wire. Then, we tried retrograde wiring again. Finally, after difficult guide wire negotiation, we could retrogradely pass a Shevalier 14 tapered 30 guide wire to the abdominal aorta. Next, we retrogradely approached the left CIA occlusion. We patiently performed guide wire manipulation, but finally failed to cross the guide wire on the left side. We finished the procedure with a 6.0×40-mm balloon catheter inflation from the aorta to right CIA in this session. Two weeks after the first session, we retried this case and finally succeeded in crossing a Naveed Hard 30 from the left external iliac artery to the terminal aorta. After pre-dilation on the left side with a 6.0 × 40 mm balloon catheter, we implanted two 8.0 × 100 mm self-expandable nitinol SMART stents with kissing stent maneuver. Final angiography and computed tomography demonstrated a good expansion of stents and favorable blood flow on both sides.
The aorto-iliac occlusive disease (AIOD) is categorized as a type D aorto-iliac lesion in TASC II guideline. Although surgical reconstruction is firstly recommended in patients with AIOD, more patients in Japan have not underwent open surgery, but rather endovascular treatment (EVT). The rates of both primary and secondary patency for open bypass are superior to those for EVT in patients with AIOD. However, surgery carries a higher risk of perioperative complications and 30-day mortality than EVT. Therefore, clinicians should select the procedure based on the characteristics of the lesion and the patient’s comorbidities and or wishes.