- Email: [email protected]
TCTAP C-222 Successful Limb Salvage Case of Critical Limb Ischemia Patient with Systemic Sclerosis Treated by Endovascular Therapy in Combination with Lumbar Sympathetic Nerve Blockade
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
S309
[INTERVENTIONAL MANAGEMENT] Procedural step. We used ipsilateral approach. 0.014 inchs Command wire (Abbott Vascular, Illinois) was able to penetrate the SFA occlusive lesion by intravascular ultrasound (IVUS) knuckle technique without bi-directional approach. As a large amount of clot was aspirated, the SFA occlusive lesion was dilated by 5 mm balloon and 6 mm self expandable bare metal stent was implanted under deployment of distal protection device at popliteal artery. After no distal embolism to BTK lesion was affirmed, we tried EVT to BTK lesion consequently. We tried angioplasty in the ATA long occluded lesion, but failed to cross it because of too tiny vessel distal to the lesion at below the ankle (BTA), which converted to anlioplastyin severe stenosis of tibioperoneal trunk. To increase collateral flow to pedal artery, we selected 2 mm balloon to dilate tibioperoneal trunk. Final angiogram shown as Figure 3. As systemic vascular disease related with lcSSc and presence of ischemic pain could make vessel at BTA lesion more narrow, lumbar sympathetic nerve blockade was introduced to the patient. SPPs at her right dorsal and plantar on the day after the indexed EVT were 21 and 14 mmHg, respectively. At 9 days after lumbar sympathetic nerve blockade, her rest pain was relieved and SPPs increased to 35 and 45 mmHg. Unfortunately, the tips of all her right toes turned to black (Figure 4), which resulted in metatarsal amputation inevitably. Six months later, she walked to our clinic without training wheels.
Case Summary. The coronary vein stenosis are rare. Reported incidence is around 1.83%, with higher chances in post myocardial infarction and CABG patients. Stenosis and small-caliber veins can be successfully dilated with standard coronary angioplasty catheters without any intra operative or postoperative complications. Therefore, this option should always be explored before sending the patients for open surgical lead implantation. TCTAP C-222 Successful Limb Salvage Case of Critical Limb Ischemia Patient with Systemic Sclerosis Treated by Endovascular Therapy in Combination with Lumbar Sympathetic Nerve Blockade Takumi Inoue,1 Susumu Odajima,2 Kentaro Yamashita,1 Taro Kamada,1 Shun Yokota,1 Daisuke Tsuda,1 Masamichi Iwasaki,1 Hiroshi Okamoto,1 Takatoshi Hayashi1 1 Hyogo Prefectural Awaji Medical Center, Japan; 2Hyogo prefectural awaji medical center, Japan [CLINICAL INFORMATION] Patient initials or identifier number. E.S Relevant clinical history and physical exam. A 87 years-old woman suffers from coldness of her each finger every winter. This ambulatory woman had rest pain in her right foot 2 months ago, and referred to our hospital with a deeply erythematous on her right foot. Past medical history included hypertension alone. She did not have any episode of smoking, diabetes, and intermittent claudication. At clinical examination, her right leg was extremely painful and edematous, and intractable skin ulcers emerged on from her 2nd to 4th fingers. Relevant test results prior to catheterization. A Initial laboratory examination revealed left shift of leucocyte without C-reactive protein (CRP) elevation (Leucocyte 6,700/ ml, granulocyte 93.1%, CRP 0.43 mg/ dl), normal renal function,positive anti-centro-mere, anti-SSA and anti-SSB antibody test. Based on these antibody test, we made a diagnosis of limited cutaneous systemic sclerosis (lcSSc) with Sjögren’s syndrome. Her right ankle/brachial index (ABI) was unmeasurable. Skin perfusion pressure (SPP) of her right plantar was 7 mmHg. Relevant catheterization findings. Initial angiogram showed around 15 cm occlusion of right superficial femoral artery (SFA), total occlusion of right anterior tibialis (ATA), posterior tibialis (PTA), and peroneal artery (PA), and severe stenosis of tibioperoneal trunk supplied collateral flow to pedal artery, resulted in very little pedal filling. Then we tried endovascular therapy (EVT) to right SFA occlusive disease and to below the knee (BTK).
S310
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
from the posterior tibial artery to the popliteal artery with a 1.5 mm to 4.0 mm balloon. The final blood flow of the native artery was superior to that of the bypass graft; and the pulse of the posterior tibial artery reversed; this indicated that the bypass graft flow might not affect the patency of the native artery, and occluded in the near future.
Case Summary. A combination with endovascular therapy and lumbar sympathetic nerve blockade could escape from major amputation for patients suffered from critical limb ischemia with poor runoff artery to below the ankle, especially concomitant with collagen disease, such as systemic sclerosis. TCTAP C-223 Endovascular Treatment for the Native Popliteal Artery After Bypass Surgery Due to Popliteal Artery Entrapment Syndrome: How Can We Evaluate the Intravascular Imaging at the Distal Anastomosis Site? Keisuke Nakabayashi,1 Hiroshi Ando,1 Nobuhito Kaneko,1 Minoru Shimizu1 1 Kasukabe Chuo General Hospital, Japan [CLINICAL INFORMATION] Patient initials or identifier number. WM Relevant clinical history and physical exam. A 45 year-old man was diagnosed with right popliteal artery entrapment syndrome by acute limb ischemia. A femoro-posterior tibial artery bypass and release of the entrapment were performed. He developed a right, intermittent claudication one year after the surgery due to noncompliance with his antiplatelet treatment. He was transferred to our institution for the purpose of endovascular treatment, as he refused re-surgery. Relevant test results prior to catheterization. Ankle Brachial Pressure Index: right 0.61/ left 1.25 CT: Both the right popliteal bypass graft and the native popliteal artery were occluded The latter was also shrunken A pseudoaneurysm suspected on the right common femoral artery Relevant catheterization findings. The right native popliteal artery and the bypass graft were occluded with rich collateral and had no stump. A posterior tibial artery suitable for distal puncture was available. [INTERVENTIONAL MANAGEMENT] Procedural step. We chose the contralateral approach due to the pseudoaneurysm on the right femoral artery. The angiography showed no stump of the native artery and bypass graft. The intravascular ultrasound from the collateral artery indicated the entry of the bypass graft, not the native artery. First, we advanced the stiff wire to the distal anastomosis site, then punctured the posterior tibial artery and inserted the micro catheter in order to use a bidirectional approach. The retrograde wire crossed the occluded bypass graft by the kissing wire technique, and wire externalization was established. After thrombus aspiration and dilation via a 1.5 mm balloon, the intravascular ultrasound eventually delineated the distal anastomosis site that indicated the exit of occluded native artery. Thereafter, the retrograde stiff wire punctured the exit of the occluded native artery. The middle of the occluded native artery was so hard, due to fibrous plaque, that we used the knuckle wire technique in order to not exit the vessel. Finally, the retrograde wire re-established the wire externalization by a rendezvous technique. We created dilation
S309
[INTERVENTIONAL MANAGEMENT] Procedural step. We used ipsilateral approach. 0.014 inchs Command wire (Abbott Vascular, Illinois) was able to penetrate the SFA occlusive lesion by intravascular ultrasound (IVUS) knuckle technique without bi-directional approach. As a large amount of clot was aspirated, the SFA occlusive lesion was dilated by 5 mm balloon and 6 mm self expandable bare metal stent was implanted under deployment of distal protection device at popliteal artery. After no distal embolism to BTK lesion was affirmed, we tried EVT to BTK lesion consequently. We tried angioplasty in the ATA long occluded lesion, but failed to cross it because of too tiny vessel distal to the lesion at below the ankle (BTA), which converted to anlioplastyin severe stenosis of tibioperoneal trunk. To increase collateral flow to pedal artery, we selected 2 mm balloon to dilate tibioperoneal trunk. Final angiogram shown as Figure 3. As systemic vascular disease related with lcSSc and presence of ischemic pain could make vessel at BTA lesion more narrow, lumbar sympathetic nerve blockade was introduced to the patient. SPPs at her right dorsal and plantar on the day after the indexed EVT were 21 and 14 mmHg, respectively. At 9 days after lumbar sympathetic nerve blockade, her rest pain was relieved and SPPs increased to 35 and 45 mmHg. Unfortunately, the tips of all her right toes turned to black (Figure 4), which resulted in metatarsal amputation inevitably. Six months later, she walked to our clinic without training wheels.
Case Summary. The coronary vein stenosis are rare. Reported incidence is around 1.83%, with higher chances in post myocardial infarction and CABG patients. Stenosis and small-caliber veins can be successfully dilated with standard coronary angioplasty catheters without any intra operative or postoperative complications. Therefore, this option should always be explored before sending the patients for open surgical lead implantation. TCTAP C-222 Successful Limb Salvage Case of Critical Limb Ischemia Patient with Systemic Sclerosis Treated by Endovascular Therapy in Combination with Lumbar Sympathetic Nerve Blockade Takumi Inoue,1 Susumu Odajima,2 Kentaro Yamashita,1 Taro Kamada,1 Shun Yokota,1 Daisuke Tsuda,1 Masamichi Iwasaki,1 Hiroshi Okamoto,1 Takatoshi Hayashi1 1 Hyogo Prefectural Awaji Medical Center, Japan; 2Hyogo prefectural awaji medical center, Japan [CLINICAL INFORMATION] Patient initials or identifier number. E.S Relevant clinical history and physical exam. A 87 years-old woman suffers from coldness of her each finger every winter. This ambulatory woman had rest pain in her right foot 2 months ago, and referred to our hospital with a deeply erythematous on her right foot. Past medical history included hypertension alone. She did not have any episode of smoking, diabetes, and intermittent claudication. At clinical examination, her right leg was extremely painful and edematous, and intractable skin ulcers emerged on from her 2nd to 4th fingers. Relevant test results prior to catheterization. A Initial laboratory examination revealed left shift of leucocyte without C-reactive protein (CRP) elevation (Leucocyte 6,700/ ml, granulocyte 93.1%, CRP 0.43 mg/ dl), normal renal function,positive anti-centro-mere, anti-SSA and anti-SSB antibody test. Based on these antibody test, we made a diagnosis of limited cutaneous systemic sclerosis (lcSSc) with Sjögren’s syndrome. Her right ankle/brachial index (ABI) was unmeasurable. Skin perfusion pressure (SPP) of her right plantar was 7 mmHg. Relevant catheterization findings. Initial angiogram showed around 15 cm occlusion of right superficial femoral artery (SFA), total occlusion of right anterior tibialis (ATA), posterior tibialis (PTA), and peroneal artery (PA), and severe stenosis of tibioperoneal trunk supplied collateral flow to pedal artery, resulted in very little pedal filling. Then we tried endovascular therapy (EVT) to right SFA occlusive disease and to below the knee (BTK).
S310
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
from the posterior tibial artery to the popliteal artery with a 1.5 mm to 4.0 mm balloon. The final blood flow of the native artery was superior to that of the bypass graft; and the pulse of the posterior tibial artery reversed; this indicated that the bypass graft flow might not affect the patency of the native artery, and occluded in the near future.
Case Summary. A combination with endovascular therapy and lumbar sympathetic nerve blockade could escape from major amputation for patients suffered from critical limb ischemia with poor runoff artery to below the ankle, especially concomitant with collagen disease, such as systemic sclerosis. TCTAP C-223 Endovascular Treatment for the Native Popliteal Artery After Bypass Surgery Due to Popliteal Artery Entrapment Syndrome: How Can We Evaluate the Intravascular Imaging at the Distal Anastomosis Site? Keisuke Nakabayashi,1 Hiroshi Ando,1 Nobuhito Kaneko,1 Minoru Shimizu1 1 Kasukabe Chuo General Hospital, Japan [CLINICAL INFORMATION] Patient initials or identifier number. WM Relevant clinical history and physical exam. A 45 year-old man was diagnosed with right popliteal artery entrapment syndrome by acute limb ischemia. A femoro-posterior tibial artery bypass and release of the entrapment were performed. He developed a right, intermittent claudication one year after the surgery due to noncompliance with his antiplatelet treatment. He was transferred to our institution for the purpose of endovascular treatment, as he refused re-surgery. Relevant test results prior to catheterization. Ankle Brachial Pressure Index: right 0.61/ left 1.25 CT: Both the right popliteal bypass graft and the native popliteal artery were occluded The latter was also shrunken A pseudoaneurysm suspected on the right common femoral artery Relevant catheterization findings. The right native popliteal artery and the bypass graft were occluded with rich collateral and had no stump. A posterior tibial artery suitable for distal puncture was available. [INTERVENTIONAL MANAGEMENT] Procedural step. We chose the contralateral approach due to the pseudoaneurysm on the right femoral artery. The angiography showed no stump of the native artery and bypass graft. The intravascular ultrasound from the collateral artery indicated the entry of the bypass graft, not the native artery. First, we advanced the stiff wire to the distal anastomosis site, then punctured the posterior tibial artery and inserted the micro catheter in order to use a bidirectional approach. The retrograde wire crossed the occluded bypass graft by the kissing wire technique, and wire externalization was established. After thrombus aspiration and dilation via a 1.5 mm balloon, the intravascular ultrasound eventually delineated the distal anastomosis site that indicated the exit of occluded native artery. Thereafter, the retrograde stiff wire punctured the exit of the occluded native artery. The middle of the occluded native artery was so hard, due to fibrous plaque, that we used the knuckle wire technique in order to not exit the vessel. Finally, the retrograde wire re-established the wire externalization by a rendezvous technique. We created dilation