TCTAP & AP VALVES 2020 Virtual

CASE20190912_001

ENDOVASCULAR - Peripheral Vascular Disease and Intervention
Endovascular Sharp Recanalization for Calcified Femoropopliteal Artery Occlusion: A Challenge
Md Moynul Islam¹, Asraful Hoque¹
National Institute of Cardiovascular Diseases (NICVD), Bangladesh¹,

[Clinical Information] - Patient initials or identifier number: 0001226,000564 -Relevant clinical history and physical exam: A 59 year old womanwith history of hypertension, end-stage renal disease, and left femoropoplitealartery bypass was referred to our institute because of gangrene of the leftthird toe and intractable pain. An 65-year-old manvisited our hospital with critical left limb ischemia and impending footcyanosis. The patient had a history of hypertension, diabetes mellitus, andcoronary bypass surgery and had undergone SFA stenting and below-the-knee (BTK)angioplasty for the right leg. ABI was 0.45. -Relevant test results prior to catheterization: Duplex study of 1stpatient revealed atherosclerotic lesion in the lumen of left superficialfemoral artery and calcified lesion in the mid part of the artery. Some collaterals were seensupplying the distal portion of the SFA and tibial arteries. Duplex study of 2nd patientrevealed atherosclerotic lesion in the mid part of the lumen of left SFA. - Relevant catheterization findings: Angiography (1stpatient) revealed occlusion of the left superficial femoral artery (SFA) fromits ostium with collateralssupplying the distaportion of the SFA and tibial arteries and the diagnostic angiography (2nd patient) revealed heavily calcifiedocclusions in the proximal popliteal artery and very slow blood flow to the BTKarea.
[Interventional Management] - Procedural step: Case-1: A59-year-old woman with femoropopliteal artery bypass performed 3 years ago wasreferred to our institute for EVI because of gangrene of the left third toe andintractable pain. Angiography revealed occlusion of the left superficialfemoral artery(SFA)and tibial arteries. Successful antegrade arterial puncturewas done but lesion crossing was unsuccessful because of hard plaque, latercarefully probed and penetrated (Pic 1). Angioplasty was performed and two long EdwardsSelf-Expanding Lifestents were deployed. Good angiographic results wereobtained and after the intervention, the ischemic symptoms resolved, and the ABI increased (Fig 2)Case-2: An65-year-old man with critical left limbischemia and S/P coronary bypass surgery had underwent SFA stenting and below-the-knee(BTK) angioplasty for the right leg in 2014. Angiography revealed calcifiedocclusions in the proximal popliteal artery and slow blood flow to the BTKarea. The antegrade flow was further compromised because of unsuccessful wirecrossing and subintimal tracking in the region of the calcified plaque. Lesionwas probed, ballon angioplasty was performed. Atherosclerotic emboli were notedin the middle region of the peroneal artery after sharp recanalization. Theseemboli were suctioned out and a stent was positioned in the proximal poplitealartery. Good angiographic result without evidence of distal embolism wasobtained. Pic1.docx Pic 2.docx - Case Summary: Endovascular intervention of peripheral chronic total occlusion (CTO) is technically challenging and time consuming. Various techniques and devices are used to facilitate lesion crossing and improve the success rate of the procedure.However, these new devices are quite expensive and not readily available. Wereport 2 cases of peripheral CTO wherein the occlusions were successfully crossed by using stiff end of Terumo glide wire. This sharp recanalization may be a useful technique for the recanalization of calcified peripheral CTOs when conventional techniques fail and new devices are not readily available, but it is accompanied by the risk of distal atheroembolism.

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