A Case of Complete Salvage of Critical Limb Ischemia with Total Occlusion from Common Iliac Artery to Superficial Femoral Artery
- Operator : Hiroaki Fujie
|A Case of Complete Salvage of Critical Limb Ischemia with Total Occlusion from Common Iliac Artery to Superficial Femoral Artery|
|- Operator: Hiroaki Fujie, MD|
|82-year old gentleman with dyslipidemia was admitted to our hospital with sudden-onset significant left below-knee cyanosis combined with ulceration and infection at left 3rd and 4th toes which showed gangrenous changes (Figure 1, Figure 2).
Laboratory tests on admission were as follows ; WBC 8600/•žl, CRP 5.1mg/dl, CPK 632U/I. MR angiography showed total occlusion of left CIA ostium with multiple bridge collateral, so we decided to perform emergency angiography.
|Baseline Catheterization Findings|
|The emergent peripheral angiography showed total occlusion of left CIA to CFA, and diffuse long SFA CTO lesion, in which partially revealed true lumen by multiple collateral flow ( Movie 1).|
|Left CIA was cannulated with a 6Fr IMA guiding catheter with side hole through right femoral approach. We tried antegrade approach at CIA ostium by using a 0.014 inch Cruise with Transit2 135cm microcatheter (Figure 3). After negotiation, pre-dilation was performed with Jackal OTW 3.0-100mm through left CFA (Figure 4). First target was left CIA lesion. However, tip injection from microcatheter showed that deep femoral arterial flow was very weak ( Movie 2), indicating that both left SFA CTO lesion and left CIA lesion should be treated. Then we tried antegrade approach for left SFA using 0.014 inch Ruby intermediate supported with AMPHiRion DEEP OTW 1.5-20mm balloon catheter. However, the wire was not easily advanced into SFA CTO lesion, we changed guiding catheter from 6Fr IMA to 6Fr Destination 45cm ( Movie 3). We performed step-up wiring; 0.014 inch Cruise, RunthroughPh, Treasure XS, Treasure XS12, Astato XS, X-tremePV. At the same time, we performed several balloon dilations for proximal SFA with AMPHiRion DEEP OTW 1.5-20mm, Jackal OTW 2.0-100mm, and Jackal OTW 3.0-100mm, however those wires could not pass through the SFA CTO lesion. At this time, we tried knuckle wire technique by using 0.035 inch Radifocus wire, and passed through whole CTO lesion to popliteal artery ( Movie 4, Movie 5). And then, we succeeded in the engagement of wire into distal left PTA with 0.014 inch AstatoXS ( Movie 6). After pre-dilation, we deployed 3 consecutive stents with overlapping at left SFA (SmartControl 6.0-100mm, 7.0-100mm and 7.0-100mm). Adjunctive ballooning using Jackal OTW 4.0-100mm was performed ( Movie 7). Finally, we deployed 2 consecutive stents with overlapping at left CFA to CIA (SmartControl 8.0-100mm, 8.0-80mm). Adjunctive ballooning using Jackal OTW 5.0-100mm and UltrathinDiamond 6.0-20mm ( Movie 8, Movie 9). The final angiogram showed successful revascularization from CIA to SFA CTO lesions. The next day of this procedure, left below-knee cyanosis disappeared. At 8-month follow-up, there was total healing of the ulcer, and the toe was normal (Figure 5, Figure 6).|
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