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TCTAP C-187 A Stent Fracture Disrupted Pseudoaneurysm over Second Year After Self-expandable Stents Implantation in Superficial Femoral Artery
19th CardioVascular Summit: TCTAP 2014
Case Summary: We successfully treated the isolated IAA with a small aorta at the bifurcation level with endovascular treatment.
Bilateral Renal and Common Iliac PTA with Combined Femoral and Radial Approach in Patient with Multiple Co-morbidities Amit Hooda, Purendra K. Pati Christian Medical College Hospital, Vellore, Tamil Nadu, India
[Interventional Management] Procedural step: Right internal iliac artery was selected with 5 Fr multi-purpose catheter under 035inch guidewire and it was occluded with 8-mm Amplatzer vascular plug. Main body (Gore Excluder 23-14-12 mm) was deployed through the left common femoral artery (CFA) sheath (16 Fr). Right leg body (Gore Excluder 16-10-7 mm) was deployed through the right CFA sheath (12 Fr). Right leg body extension (Gore Excluder 12-14 mm) was finally deployed. Adjuvant PTA balloon (32 mm) was inserted and inflated at stent graft several times. Final angiography showed good position and no leakage at both main body and right leg body. Also, there were no differences in blood pressure between the two arteries distal to the leg bodies.
[Clinical Information] Patient initials or identifier number: SD Relevant clinical history and physical exam: A 61/M Uncontrolled DM II-13 yrs HTN-6 yrs, chronic smoker Old IWMI, claudication bilateral lower limbs with non-healing right foot ulcer Absent lower limb pulses except femorals which are feeble Relevant test results prior to catheterization: S.Cr-1.61mg/dl, eGFR-40 mL/min/1.73 m2 ABI R-0.21, L-0.43 Relevant catheterization findings: Triple vessel coronary artery disease with severe diffuse peripheral arterial disease and bilateral renal artery stenosis [Interventional Management] Procedural step: 1. B/L RENAL PTA 7F Left transfemoral and 6F Left radial access Heparin- 100 units/kg Wire couldn’t be negotiated through the iliac plaque Lesion crossed from above, wire exteriorized and a 7F JR guide was used to engage Rt renal Predilation-2.75, 4 mm balloon at 10 atm 7 x 12 mm Herculink (Abbott Vascular, Santa Clara, CA) at 12 atm Post dilated to 14 atm Left renal artery stented with 5.5 x 10 mm Herculink (Abbott Vascular, Santa Clara, CA) at 10 atm Post dilated to 14 atm 2. CIA PTA The tight right common iliac lesion was crossed and an ASS with 1 m ST was inserted. A 9 x 80 mm self expanding stent Absolute pro (Abbott Vascular, Santa Clara, CA) was taken across and was deployed under fluoroscopy. The original stented segment post dilated by 5 x 40 mm balloon at 12 atm. Good result. The left Common iliac was stented by another 9 x 60 mm self expanding Absolute pro stent (Abbott Vascular, Santa Clara, CA) deployed under fluoroscopy. Post dilated by 7 x 20 mm balloon at 14 atm. Good result. Case Summary: A 61/M chronic smoker, hypertensive with uncontrolled diabetes mellitus II and nephropathy presented with severe peripheral arterial disease and bilateral renal artery stenosis. He was refused for surgery in view of comorbidities. Renal artery stenting was done using combined radial and femoral approach with judicious use of hydration and contrast. TCTAP C-187 A Stent Fracture Disrupted Pseudoaneurysm over Second Year After Selfexpandable Stents Implantation in Superficial Femoral Artery Tetsuo Horimatsu Hyogo College of Medicine, Japan [Clinical Information] Patient initials or identifier number: B.Y Relevant clinical history and physical exam: A 89-years-old man, who had hypertension, presented with swelling of his left thigh after rehabilitation. Four years ago, the patient underwent primary stenting of the left SFA to treat total occlusion (TASC D) with four overlapping self-expandable stents (Smart, Cordis), and two years ago, added one stent because stent occlusion at ostium of SFA. Relevant test results prior to catheterization: ABI was 0.94 on left side. Blood examination showed progression of anemia. Contrast CT showed a huge hematoma in the left thigh and leakage of contrast agents from SFA. Relevant catheterization findings: Initial angiogram showed a stent fracture at mid portion of SFA and leakage of those. [Interventional Management] Procedural step: First, Balloon angioplasty performed to hemostasis in lesion with 7*40mm (Bandicoot, St.Jude Medical), but it was occluded with thrombus. Therefore, we attempted to thrombectomy with fogarty catheter. An aneurysm was directly observed in 10cm distal from femoral bifurcation. When dissecting the aneurysm, it was confirmed thrombus mixed fresh and organized, fractured stent struts and lacerated foramen. Thrombectomy was performed through the foramen with fogarty catheter, and the fractured stent struts were resected. After the foramen was repaired with patch, final angiogram showed no distal embolism.
JACC Vol 63/12/Suppl S
j
April 22–25, 2014
j
TCTAP Abstracts/CASE/Peripheral Vascular Intervention (Non-carotid, Non-neurovascular) S181
CASES
TCTAP C-186
CASES
19th CardioVascular Summit: TCTAP 2014
Case Summary: In conclusion, this case was complicated with pseudoaneurysm after stent implantation, subsequently fractured stent struts disrupted aneurysm. There is no report that rupture of pseudoaneurysm was complicated after SFA stenting. TCTAP C-188 Renal Denervation in a Patient with Type B Aortic Dissection and Resistant Hypertension Martin Horváth, David Zemanek Motol Hospital, Czech Republic [Clinical Information] Patient initials or identifier number: MM Relevant clinical history and physical exam: 39-year-old male, caucasian. No history of internal comorbidities Admitted with back pain and transient lower limb plegia A history of the same symptoms 4 weeks prior to examination Relevant test results prior to catheterization: CT scan: Stanford type B aortic dissection Relevant catheterization findings: renal angiography, two renal arteries without any significant stenosis [Interventional Management] Procedural step: Stentgraft implantation After preparation of the left femoral artery a Lunderquist guidewire (Cook medical, Bloomington, IN) was implanted. After punction of the right femoral artery with a 6F sheath a 5F pigtail catheter (Cook medical, Bloomington, IN) was implanted within the aortic arch. Subsequently a two segment stentgraft (Zenith TX2, Cook medical, Bloomignton, IN) was deployed in a manner that it started right behind the origin of the left subclavian artery and ended just proximal to the origin of the coeliac trunk. Renal denervation. After a diagnostic angiography a radiofrequency catheter (Simplicity, Medtronic, Minneapolis, MN) was inserted within the right renal artery via right femoral artery. Radiofrequency energy was applied five times. The catheter was then inserted in the left renal artery where four radiofrequency pulses were used. A control angiography revealed a spasm of the left renal artery, which resolved itself spontaneously.
S182 JACC Vol 63/12/Suppl S
j
April 22–25, 2014
j
Case Summary: We report case of a 39-years old male patient without previous internal comorbidities admitted to our institution with a Stanford type B aortic dissection. At first a conservative approach with aggressive anti-hypertensive medication was chosen. A control CT scan revealed a progression of the dissection. We then performed an implantation of a two segment aortic stentgraft. Despite aggressive intravenous antihypertensive medication adequate blood pressure control was not possible. We decided to perform renal denervation. The procedure had an immediate effect. The patient’s blood pressure quickly normalized. TCTAP C-189 A Case of Chronic Limb Ischemia with Total Complex Popliteal Occlusion Chien-An Hsieh Taipei Buddhist Tzu-Chi General Hospital, Taiwan [Clinical Information] Patient initials or identifier number: Hu Lam Suet Relevant clinical history and physical exam: 88 years old woman has hypertension, dyslipidemia, chronic kidney disease and old stroke. She presented with gangrene change combined with ulceration and infection at left big toe for 3 week. Relevant test results prior to catheterization: Vascular ultrasonography and segmental pressure measurement exam revealed occlusion of left popliteal artery occlusion The ankle-brachial index showed very severe stenosis on both lower extremities (Rt.0.49/ Lt.0.42). Therefore, we decided to perform angiography. Relevant catheterization findings: The angiography showed total occlusion of left distal popliteal artery, PTA, peroneal artery and anterior tibial artery. The circulation of foot was only dependent on the collateral flow. By chance, the dorsalis pedis and middle segment of peroneal artery was seen. [Interventional Management] Procedural step: A 6 French sheath was placed in the left common femoral artery by antegrade approach. The multipurpose catheter 6.0 Fr was advanced into the distal popliteal artery. The 0.014 inch PT II and Astato 30 guide wire with CXI microcatheter was successful to negotiate the totally peroneal lesion. After dilation popliteal artery and peroneal artery using Pacific 4.0*80mm, Pacific 2.0*120 mm and sprinter 3.0*15mm, the angiography showed real rout of the peroneal artery, also middle ATA was seem by better collateral circulation. Then, we performed retrograde dorsal pedis puncture by fluoroscopy guide. We used Wire-balloon-only technique for avoid distal vessel trauma. Retrograde wire advanced to proximal ATA but it could not pass though the occlusion. Retrograde loop technique was performed with V-18 J-configuration under CXI support, but it couldn’t re-entry into popliteal artery true lumen. Antegrade approach was done by wiring proximal subintimal ATA with a 0.014 miracle 6. CART technique was performed at proximal ATA with dual balloon dilation at antegrade and retrograde direction. After dissection membrane was interrupted, wire advanced smoothly to distal ATA. A 2.0*120 Pacific and another 3.5*40 ampirion balloon were used for dilation ATA. A 4.0*12 mm drug eluting balloon was used for treating popliteal artery. Final, angiography revealed popliteal arteryand ATA recanalization successful. Distal run off of left foot was improved.
TCTAP Abstracts/CASE/Peripheral Vascular Intervention (Non-carotid, Non-neurovascular)
Case Summary: We successfully treated the isolated IAA with a small aorta at the bifurcation level with endovascular treatment.
Bilateral Renal and Common Iliac PTA with Combined Femoral and Radial Approach in Patient with Multiple Co-morbidities Amit Hooda, Purendra K. Pati Christian Medical College Hospital, Vellore, Tamil Nadu, India
[Interventional Management] Procedural step: Right internal iliac artery was selected with 5 Fr multi-purpose catheter under 035inch guidewire and it was occluded with 8-mm Amplatzer vascular plug. Main body (Gore Excluder 23-14-12 mm) was deployed through the left common femoral artery (CFA) sheath (16 Fr). Right leg body (Gore Excluder 16-10-7 mm) was deployed through the right CFA sheath (12 Fr). Right leg body extension (Gore Excluder 12-14 mm) was finally deployed. Adjuvant PTA balloon (32 mm) was inserted and inflated at stent graft several times. Final angiography showed good position and no leakage at both main body and right leg body. Also, there were no differences in blood pressure between the two arteries distal to the leg bodies.
[Clinical Information] Patient initials or identifier number: SD Relevant clinical history and physical exam: A 61/M Uncontrolled DM II-13 yrs HTN-6 yrs, chronic smoker Old IWMI, claudication bilateral lower limbs with non-healing right foot ulcer Absent lower limb pulses except femorals which are feeble Relevant test results prior to catheterization: S.Cr-1.61mg/dl, eGFR-40 mL/min/1.73 m2 ABI R-0.21, L-0.43 Relevant catheterization findings: Triple vessel coronary artery disease with severe diffuse peripheral arterial disease and bilateral renal artery stenosis [Interventional Management] Procedural step: 1. B/L RENAL PTA 7F Left transfemoral and 6F Left radial access Heparin- 100 units/kg Wire couldn’t be negotiated through the iliac plaque Lesion crossed from above, wire exteriorized and a 7F JR guide was used to engage Rt renal Predilation-2.75, 4 mm balloon at 10 atm 7 x 12 mm Herculink (Abbott Vascular, Santa Clara, CA) at 12 atm Post dilated to 14 atm Left renal artery stented with 5.5 x 10 mm Herculink (Abbott Vascular, Santa Clara, CA) at 10 atm Post dilated to 14 atm 2. CIA PTA The tight right common iliac lesion was crossed and an ASS with 1 m ST was inserted. A 9 x 80 mm self expanding stent Absolute pro (Abbott Vascular, Santa Clara, CA) was taken across and was deployed under fluoroscopy. The original stented segment post dilated by 5 x 40 mm balloon at 12 atm. Good result. The left Common iliac was stented by another 9 x 60 mm self expanding Absolute pro stent (Abbott Vascular, Santa Clara, CA) deployed under fluoroscopy. Post dilated by 7 x 20 mm balloon at 14 atm. Good result. Case Summary: A 61/M chronic smoker, hypertensive with uncontrolled diabetes mellitus II and nephropathy presented with severe peripheral arterial disease and bilateral renal artery stenosis. He was refused for surgery in view of comorbidities. Renal artery stenting was done using combined radial and femoral approach with judicious use of hydration and contrast. TCTAP C-187 A Stent Fracture Disrupted Pseudoaneurysm over Second Year After Selfexpandable Stents Implantation in Superficial Femoral Artery Tetsuo Horimatsu Hyogo College of Medicine, Japan [Clinical Information] Patient initials or identifier number: B.Y Relevant clinical history and physical exam: A 89-years-old man, who had hypertension, presented with swelling of his left thigh after rehabilitation. Four years ago, the patient underwent primary stenting of the left SFA to treat total occlusion (TASC D) with four overlapping self-expandable stents (Smart, Cordis), and two years ago, added one stent because stent occlusion at ostium of SFA. Relevant test results prior to catheterization: ABI was 0.94 on left side. Blood examination showed progression of anemia. Contrast CT showed a huge hematoma in the left thigh and leakage of contrast agents from SFA. Relevant catheterization findings: Initial angiogram showed a stent fracture at mid portion of SFA and leakage of those. [Interventional Management] Procedural step: First, Balloon angioplasty performed to hemostasis in lesion with 7*40mm (Bandicoot, St.Jude Medical), but it was occluded with thrombus. Therefore, we attempted to thrombectomy with fogarty catheter. An aneurysm was directly observed in 10cm distal from femoral bifurcation. When dissecting the aneurysm, it was confirmed thrombus mixed fresh and organized, fractured stent struts and lacerated foramen. Thrombectomy was performed through the foramen with fogarty catheter, and the fractured stent struts were resected. After the foramen was repaired with patch, final angiogram showed no distal embolism.
JACC Vol 63/12/Suppl S
j
April 22–25, 2014
j
TCTAP Abstracts/CASE/Peripheral Vascular Intervention (Non-carotid, Non-neurovascular) S181
CASES
TCTAP C-186
CASES
19th CardioVascular Summit: TCTAP 2014
Case Summary: In conclusion, this case was complicated with pseudoaneurysm after stent implantation, subsequently fractured stent struts disrupted aneurysm. There is no report that rupture of pseudoaneurysm was complicated after SFA stenting. TCTAP C-188 Renal Denervation in a Patient with Type B Aortic Dissection and Resistant Hypertension Martin Horváth, David Zemanek Motol Hospital, Czech Republic [Clinical Information] Patient initials or identifier number: MM Relevant clinical history and physical exam: 39-year-old male, caucasian. No history of internal comorbidities Admitted with back pain and transient lower limb plegia A history of the same symptoms 4 weeks prior to examination Relevant test results prior to catheterization: CT scan: Stanford type B aortic dissection Relevant catheterization findings: renal angiography, two renal arteries without any significant stenosis [Interventional Management] Procedural step: Stentgraft implantation After preparation of the left femoral artery a Lunderquist guidewire (Cook medical, Bloomington, IN) was implanted. After punction of the right femoral artery with a 6F sheath a 5F pigtail catheter (Cook medical, Bloomington, IN) was implanted within the aortic arch. Subsequently a two segment stentgraft (Zenith TX2, Cook medical, Bloomignton, IN) was deployed in a manner that it started right behind the origin of the left subclavian artery and ended just proximal to the origin of the coeliac trunk. Renal denervation. After a diagnostic angiography a radiofrequency catheter (Simplicity, Medtronic, Minneapolis, MN) was inserted within the right renal artery via right femoral artery. Radiofrequency energy was applied five times. The catheter was then inserted in the left renal artery where four radiofrequency pulses were used. A control angiography revealed a spasm of the left renal artery, which resolved itself spontaneously.
S182 JACC Vol 63/12/Suppl S
j
April 22–25, 2014
j
Case Summary: We report case of a 39-years old male patient without previous internal comorbidities admitted to our institution with a Stanford type B aortic dissection. At first a conservative approach with aggressive anti-hypertensive medication was chosen. A control CT scan revealed a progression of the dissection. We then performed an implantation of a two segment aortic stentgraft. Despite aggressive intravenous antihypertensive medication adequate blood pressure control was not possible. We decided to perform renal denervation. The procedure had an immediate effect. The patient’s blood pressure quickly normalized. TCTAP C-189 A Case of Chronic Limb Ischemia with Total Complex Popliteal Occlusion Chien-An Hsieh Taipei Buddhist Tzu-Chi General Hospital, Taiwan [Clinical Information] Patient initials or identifier number: Hu Lam Suet Relevant clinical history and physical exam: 88 years old woman has hypertension, dyslipidemia, chronic kidney disease and old stroke. She presented with gangrene change combined with ulceration and infection at left big toe for 3 week. Relevant test results prior to catheterization: Vascular ultrasonography and segmental pressure measurement exam revealed occlusion of left popliteal artery occlusion The ankle-brachial index showed very severe stenosis on both lower extremities (Rt.0.49/ Lt.0.42). Therefore, we decided to perform angiography. Relevant catheterization findings: The angiography showed total occlusion of left distal popliteal artery, PTA, peroneal artery and anterior tibial artery. The circulation of foot was only dependent on the collateral flow. By chance, the dorsalis pedis and middle segment of peroneal artery was seen. [Interventional Management] Procedural step: A 6 French sheath was placed in the left common femoral artery by antegrade approach. The multipurpose catheter 6.0 Fr was advanced into the distal popliteal artery. The 0.014 inch PT II and Astato 30 guide wire with CXI microcatheter was successful to negotiate the totally peroneal lesion. After dilation popliteal artery and peroneal artery using Pacific 4.0*80mm, Pacific 2.0*120 mm and sprinter 3.0*15mm, the angiography showed real rout of the peroneal artery, also middle ATA was seem by better collateral circulation. Then, we performed retrograde dorsal pedis puncture by fluoroscopy guide. We used Wire-balloon-only technique for avoid distal vessel trauma. Retrograde wire advanced to proximal ATA but it could not pass though the occlusion. Retrograde loop technique was performed with V-18 J-configuration under CXI support, but it couldn’t re-entry into popliteal artery true lumen. Antegrade approach was done by wiring proximal subintimal ATA with a 0.014 miracle 6. CART technique was performed at proximal ATA with dual balloon dilation at antegrade and retrograde direction. After dissection membrane was interrupted, wire advanced smoothly to distal ATA. A 2.0*120 Pacific and another 3.5*40 ampirion balloon were used for dilation ATA. A 4.0*12 mm drug eluting balloon was used for treating popliteal artery. Final, angiography revealed popliteal arteryand ATA recanalization successful. Distal run off of left foot was improved.
TCTAP Abstracts/CASE/Peripheral Vascular Intervention (Non-carotid, Non-neurovascular)