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TCTAP C-191 Spontaneous Rupture of a Posterior Tibial Artery with Neurofibromatosis Type 1 Treated by Coil Embolization
S326
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
ENDOVASCULAR: PERIPHERAL VASCULAR DISEASE AND INTERVENTION (TCTAP C-190 TO TCTAP C-223) TCTAP C-190 Successful Revascularization of Isolated SMA Dissection Junichi Tazaki,1 Takeshi Kimura1 1 Kyoto University Hospital, Japan [CLINICAL INFORMATION] Patient initials or identifier number. T.T Relevant clinical history and physical exam. Fifty-five y.o. male was admitted to our hospital due to severe abdominal pain, nausea and vomit with acute onset. He had no past history of admission and he was current smoking and had mild hypertension without treatment. Abdominal pain was decreased at admission, therefore we decided to treat conservatively at first. However severe abdominal pain relapsed on Day 4. Relevant test results prior to catheterization. ECG: Sinus rhythm ABG: pH 7.414 pO2 71 pCO2 38 BE-0.8 Emergent CT revealed isolated SMA dissection. Relevant catheterization findings. AoG revealed entry point at proximal portion of SMA. [INTERVENTIONAL MANAGEMENT] Procedural step. We decided strategyguided by CT 3D view. CT showed true lumen was compressed by false lumen, andall branches were from true lumen. Therefore we planned implant self- expandingstent at true lumen to close primary entry and maintain blood flow of truelumen. We inserted 6.5Frsheath less PV guiding from lest brachial artery. We cross 0.014 Agosal guide wire tothe true lumen with non-touch technique. IVUS showed truelumen was compressed and false lumen was blind end. At first, weimplanted 8mm Misago stent at ostium of SMA to close primary entry. However, flow of true lumen was not fully improved after stent implantation. Becausefalse lumen did not have reentry, pressure at distal portion of false lumen wasstiff high after primary entry closure. Therefore we implanted additional6mmMisago stent at distal portion of SMA true lumen. After procedure, blood flow of true lumen was improved. Final IVUS showed good expansion of truelumen.
Case Summary. After EVT, abdominal pain was improved and discharged without any complication or gastrointestinal bleeding. We report the successful revascularization of intestinal ischemia due to isolated SMA dissection supported by CT and IVUS.
TCTAP C-191 Spontaneous Rupture of a Posterior Tibial Artery with Neurofibromatosis Type 1 Treated by Coil Embolization Kanichi Otowa1 1 Municipal Tsuruga Hospital, Japan [CLINICAL INFORMATION] Patient initials or identifier number. NM Relevant clinical history and physical exam. A 50-year-old male with a medical history of xeroderma presented with a sudden right lower leg pain at rest without any trauma episode in the early morning. He was admitted to our hospital for persistent pain and swelling of his right lower leg that evening. A physical examination revealed multiple cutaneous neurofibromas under the skin of his entire body and xeroderma on his chest. The right sural region showed swelling, pain, and a feeling of heat. All peripheral pulses were palpable. Relevant test results prior to catheterization. In the laboratory findings, the white blood cell count was elevated, but CRP, FDP, and FDP ddimer were normal. Contrast-enhanced CT revealed multiple neurofibromas over the entire body and a neoplastic lesion near the right kidney measuring 98 cm. Multiple aneurysmal dilatations of both common iliac arteries were observed. In the right sural region, swelling and the leakage of contrast agents from the right posterior tibial artery were noted.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
S327
Relevant catheterization findings. Diagnostic angiography showed normal images of the right popliteal, anterior tibial, and peroneal arteries. In contrast, a ruptured aneurysm of the right posterior tibial artery was observed. [INTERVENTIONAL MANAGEMENT] Procedural step. A 4Fr sheath introducer was inserted into the right superficial femoral artery and a 4Fr straight catheter was advanced into the right popliteal artery. A 2Fr Micro-catheter (Masters ParkwayÒ ) and 0.016-inch micro guide wire (MeisterÒ ) were advanced into the posterior tibial artery passing through the arterial rupture site. Firstly, the coil anchor (Coil AnchorII Ò M) and six coils (0.018inch TornadoÒ Embolization Microcoils) were deployed on the distal side of the rupture site. Secondly, the coil anchor M and five coils (0.018-inch TornadoÒ Embolization Microcoils) were deployed on the proximal side. A final angiogram showed no evidence of visual extravasation.
S328
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
Case Summary. We report a ruptured right posterior tibial artery with neurofibromatosis type 1 successfully treated by endovascular coil embolization to completely embolize the artery by coiling both its upand downstream portions. An endovascular approach can be safe and effective in such a situation. TCTAP C-192 Below-the-knee Angioplasty by Calcification Cracking Technique with Stiff Guidewire Satoshi Tsujimoto1 1 Kansai Medical University, Japan [CLINICAL INFORMATION] Patient initials or identifier number. Y. N Relevant clinical history and physical exam. We report a case of a 72year-old woman who presented with left leg rest pain and small heel ulceration, a Rutherford classification of grade 5. She had past histories of old myocardial infarction, severe aortic valve stenosis and end stage kidney disease requiring hemodialysis. Her symptoms could not be improved by local treatment. She was considered unsuitable for surgical bypass because of severe comorbidities. Therefore we tried to perform the endovascular therapy (EVT). Relevant test results prior to catheterization. Her ankle brachial pressure index on the both side could not be measured. Relevant catheterization findings. Diagnostic angiography revealed the stenosis of left superficial femoral artery (SFA) and the total occlusion of left infrapopliteal artery with proximal portion of three run-off vessels.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
ENDOVASCULAR: PERIPHERAL VASCULAR DISEASE AND INTERVENTION (TCTAP C-190 TO TCTAP C-223) TCTAP C-190 Successful Revascularization of Isolated SMA Dissection Junichi Tazaki,1 Takeshi Kimura1 1 Kyoto University Hospital, Japan [CLINICAL INFORMATION] Patient initials or identifier number. T.T Relevant clinical history and physical exam. Fifty-five y.o. male was admitted to our hospital due to severe abdominal pain, nausea and vomit with acute onset. He had no past history of admission and he was current smoking and had mild hypertension without treatment. Abdominal pain was decreased at admission, therefore we decided to treat conservatively at first. However severe abdominal pain relapsed on Day 4. Relevant test results prior to catheterization. ECG: Sinus rhythm ABG: pH 7.414 pO2 71 pCO2 38 BE-0.8 Emergent CT revealed isolated SMA dissection. Relevant catheterization findings. AoG revealed entry point at proximal portion of SMA. [INTERVENTIONAL MANAGEMENT] Procedural step. We decided strategyguided by CT 3D view. CT showed true lumen was compressed by false lumen, andall branches were from true lumen. Therefore we planned implant self- expandingstent at true lumen to close primary entry and maintain blood flow of truelumen. We inserted 6.5Frsheath less PV guiding from lest brachial artery. We cross 0.014 Agosal guide wire tothe true lumen with non-touch technique. IVUS showed truelumen was compressed and false lumen was blind end. At first, weimplanted 8mm Misago stent at ostium of SMA to close primary entry. However, flow of true lumen was not fully improved after stent implantation. Becausefalse lumen did not have reentry, pressure at distal portion of false lumen wasstiff high after primary entry closure. Therefore we implanted additional6mmMisago stent at distal portion of SMA true lumen. After procedure, blood flow of true lumen was improved. Final IVUS showed good expansion of truelumen.
Case Summary. After EVT, abdominal pain was improved and discharged without any complication or gastrointestinal bleeding. We report the successful revascularization of intestinal ischemia due to isolated SMA dissection supported by CT and IVUS.
TCTAP C-191 Spontaneous Rupture of a Posterior Tibial Artery with Neurofibromatosis Type 1 Treated by Coil Embolization Kanichi Otowa1 1 Municipal Tsuruga Hospital, Japan [CLINICAL INFORMATION] Patient initials or identifier number. NM Relevant clinical history and physical exam. A 50-year-old male with a medical history of xeroderma presented with a sudden right lower leg pain at rest without any trauma episode in the early morning. He was admitted to our hospital for persistent pain and swelling of his right lower leg that evening. A physical examination revealed multiple cutaneous neurofibromas under the skin of his entire body and xeroderma on his chest. The right sural region showed swelling, pain, and a feeling of heat. All peripheral pulses were palpable. Relevant test results prior to catheterization. In the laboratory findings, the white blood cell count was elevated, but CRP, FDP, and FDP ddimer were normal. Contrast-enhanced CT revealed multiple neurofibromas over the entire body and a neoplastic lesion near the right kidney measuring 98 cm. Multiple aneurysmal dilatations of both common iliac arteries were observed. In the right sural region, swelling and the leakage of contrast agents from the right posterior tibial artery were noted.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
S327
Relevant catheterization findings. Diagnostic angiography showed normal images of the right popliteal, anterior tibial, and peroneal arteries. In contrast, a ruptured aneurysm of the right posterior tibial artery was observed. [INTERVENTIONAL MANAGEMENT] Procedural step. A 4Fr sheath introducer was inserted into the right superficial femoral artery and a 4Fr straight catheter was advanced into the right popliteal artery. A 2Fr Micro-catheter (Masters ParkwayÒ ) and 0.016-inch micro guide wire (MeisterÒ ) were advanced into the posterior tibial artery passing through the arterial rupture site. Firstly, the coil anchor (Coil AnchorII Ò M) and six coils (0.018inch TornadoÒ Embolization Microcoils) were deployed on the distal side of the rupture site. Secondly, the coil anchor M and five coils (0.018-inch TornadoÒ Embolization Microcoils) were deployed on the proximal side. A final angiogram showed no evidence of visual extravasation.
S328
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
Case Summary. We report a ruptured right posterior tibial artery with neurofibromatosis type 1 successfully treated by endovascular coil embolization to completely embolize the artery by coiling both its upand downstream portions. An endovascular approach can be safe and effective in such a situation. TCTAP C-192 Below-the-knee Angioplasty by Calcification Cracking Technique with Stiff Guidewire Satoshi Tsujimoto1 1 Kansai Medical University, Japan [CLINICAL INFORMATION] Patient initials or identifier number. Y. N Relevant clinical history and physical exam. We report a case of a 72year-old woman who presented with left leg rest pain and small heel ulceration, a Rutherford classification of grade 5. She had past histories of old myocardial infarction, severe aortic valve stenosis and end stage kidney disease requiring hemodialysis. Her symptoms could not be improved by local treatment. She was considered unsuitable for surgical bypass because of severe comorbidities. Therefore we tried to perform the endovascular therapy (EVT). Relevant test results prior to catheterization. Her ankle brachial pressure index on the both side could not be measured. Relevant catheterization findings. Diagnostic angiography revealed the stenosis of left superficial femoral artery (SFA) and the total occlusion of left infrapopliteal artery with proximal portion of three run-off vessels.