- Email: [email protected]
TCTAP C-258 A Complication Case of Distal Embolism During Endovascular Therapy for External Iliac Artery Occlusive Disease
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Case Summary. 1. SFA ostial CTO is not a piece of cake, and comprehensive preparation and handling of all possible complications are mandatory 2. Interventionist should be familiar with all possible antegrade and retrograde techniques when difficulties encountered 3. Safety is of the highest priority
TCTAP C-258 A Complication Case of Distal Embolism During Endovascular Therapy for External Iliac Artery Occlusive Disease Kentaro Yamashita,1 Takumi Inoue,1 Taro Kamada,1 Shun Yokota,1 Masamichi Iwasaki,1 Takatoshi Hayashi1 1 Hyogo Prefectural Awaji Medical Center, Japan [CLINICAL INFORMATION] Patient initials or identifier number. T.S. Relevant clinical history and physical exam. A 46 year-old man suffered from intermittent claudication in his left leg one year and 9 months ago. One year ago, he was diagnosed as blue toe syndrome at his left 1st toe due to thrombus embolism from occluded left external iliac artery. Since then, he had been treated optimal medical therapy for peripheral artery disease. As his intermittent claudication symptom worsened gradually, we underwent endovascular therapy for chronic total occlusion at left external iliac artery. Relevant test results prior to catheterization.
S349
S350
Relevant catheterization findings.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
[INTERVENTIONAL MANAGEMENT] Procedural step. To attempt antegrade approach first, a 6Fr sheath was inserted into the left brachial artery and located proximally from the chronic total occlusive lesion, which was passed easily by a 0.014-inch guide wire. Intravascular ultrasound images at the chronic total occlusive lesion demonstrated massive plaque burden without any calcification. Immediately after pre-dilatation by a 6.0 mm balloon, the angiogram showed that most of the plaque burden moved forward to a common femoral artery. Despite aspiration of a lot of clots, severe stenosis of an external iliac artery and total occlusion of common femoral artery still remained. With indwelling distal protection device at the superficial femoral artery, we dilated the balloon at external iliac artery-common femoral artery and implanted a self-expanded stent at the external iliac artery. Unfortunately, the thrombus moved forward to mid superficial femoral artery and was aspirated again and again. Finally, the thrombus was flown to a distal popliteal artery and completely obstructed the blood flow to his left toes, resulted in ischemic rest pain and paleness. Repeated aspiration of the thrombi recovered the blood flow to an anterior tibial artery and his symptom was disappeared.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
S351
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.
Case Summary. We experienced and bailed out a complication of distal embolism during endovascular therapy for thrombotic aorto-iliac occlusive disease, resulted in acute arterial occlusion. We have to take care of distal embolism potentially led to acute arterial occlusion when we perform endovascular therapy for suspected thrombotic aorto-iliac occlusive disease. TCTAP C-259 Successful Limb Salvage from Critical Limb Ischemia Due to Aortoiliac Occlusive Disease with Severe Calcification Tetsuya Nomura1 1 Nantan General Hospital, Japan [CLINICAL INFORMATION] Patient initials or identifier number. S.K. 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. [INTERVENTIONAL MANAGEMENT] Procedural step. 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 6.040-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
Case Summary. 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. TCTAP C-287 Salvage of Acute Limb Ischemia with Total Occlusion in Common Femoral Artery in Peripartum Cardiomyopathy Patient William Horas,1 Muzakkir Amir2 Cardiac Center of Wahidin Sudirohusodo Hospital Makassar, Indonesia; 2Department of Cardiology and Vascular Medicine, Hasanuddin University, Makassar, Indonesia 1
[CLINICAL INFORMATION] Patient initials or identifier number. N. A. Relevant clinical history and physical exam. A 33-year old female was admitted to our ER with sudden-onset pain and cyanosis in her left leg since 3 days. She had a history of baby-delivery 3 months ago and
Case Summary. 1. SFA ostial CTO is not a piece of cake, and comprehensive preparation and handling of all possible complications are mandatory 2. Interventionist should be familiar with all possible antegrade and retrograde techniques when difficulties encountered 3. Safety is of the highest priority
TCTAP C-258 A Complication Case of Distal Embolism During Endovascular Therapy for External Iliac Artery Occlusive Disease Kentaro Yamashita,1 Takumi Inoue,1 Taro Kamada,1 Shun Yokota,1 Masamichi Iwasaki,1 Takatoshi Hayashi1 1 Hyogo Prefectural Awaji Medical Center, Japan [CLINICAL INFORMATION] Patient initials or identifier number. T.S. Relevant clinical history and physical exam. A 46 year-old man suffered from intermittent claudication in his left leg one year and 9 months ago. One year ago, he was diagnosed as blue toe syndrome at his left 1st toe due to thrombus embolism from occluded left external iliac artery. Since then, he had been treated optimal medical therapy for peripheral artery disease. As his intermittent claudication symptom worsened gradually, we underwent endovascular therapy for chronic total occlusion at left external iliac artery. Relevant test results prior to catheterization.
S349
S350
Relevant catheterization findings.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
[INTERVENTIONAL MANAGEMENT] Procedural step. To attempt antegrade approach first, a 6Fr sheath was inserted into the left brachial artery and located proximally from the chronic total occlusive lesion, which was passed easily by a 0.014-inch guide wire. Intravascular ultrasound images at the chronic total occlusive lesion demonstrated massive plaque burden without any calcification. Immediately after pre-dilatation by a 6.0 mm balloon, the angiogram showed that most of the plaque burden moved forward to a common femoral artery. Despite aspiration of a lot of clots, severe stenosis of an external iliac artery and total occlusion of common femoral artery still remained. With indwelling distal protection device at the superficial femoral artery, we dilated the balloon at external iliac artery-common femoral artery and implanted a self-expanded stent at the external iliac artery. Unfortunately, the thrombus moved forward to mid superficial femoral artery and was aspirated again and again. Finally, the thrombus was flown to a distal popliteal artery and completely obstructed the blood flow to his left toes, resulted in ischemic rest pain and paleness. Repeated aspiration of the thrombi recovered the blood flow to an anterior tibial artery and his symptom was disappeared.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
S351
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.
Case Summary. We experienced and bailed out a complication of distal embolism during endovascular therapy for thrombotic aorto-iliac occlusive disease, resulted in acute arterial occlusion. We have to take care of distal embolism potentially led to acute arterial occlusion when we perform endovascular therapy for suspected thrombotic aorto-iliac occlusive disease. TCTAP C-259 Successful Limb Salvage from Critical Limb Ischemia Due to Aortoiliac Occlusive Disease with Severe Calcification Tetsuya Nomura1 1 Nantan General Hospital, Japan [CLINICAL INFORMATION] Patient initials or identifier number. S.K. 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. [INTERVENTIONAL MANAGEMENT] Procedural step. 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 6.040-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
Case Summary. 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. TCTAP C-287 Salvage of Acute Limb Ischemia with Total Occlusion in Common Femoral Artery in Peripartum Cardiomyopathy Patient William Horas,1 Muzakkir Amir2 Cardiac Center of Wahidin Sudirohusodo Hospital Makassar, Indonesia; 2Department of Cardiology and Vascular Medicine, Hasanuddin University, Makassar, Indonesia 1
[CLINICAL INFORMATION] Patient initials or identifier number. N. A. Relevant clinical history and physical exam. A 33-year old female was admitted to our ER with sudden-onset pain and cyanosis in her left leg since 3 days. She had a history of baby-delivery 3 months ago and