Bilateral LE Angiography
Crossing of CTO R popliteal
CSI R SFA and R Popliteal
PTA R SFA, R Popliteal and R PT
L Femoral and R PT Access
INDICATIONS
Patient was referred for cardiac catheterization to assess the coronary anatomy . Indications for the procedure include: Severe life limiting claudication, with prior CTO PTA R popliteal, and two prior fem-pop and fem PT bypasses. Reocclusion of R popliteal with severe disease of R SFA and R PT and occlusion of R AT on CTA of LE.
Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Patient was brought to the cath lab after IV hydration was begun and oral premedication was given. Patient was further sedated with fentanyl and versed. Patient was prepped and draped in the usual manner. Using the modified Seldinger access technique, a 6 French sheath was placed in the left femoral artery. LLE angiogram was performed.
Initial Findings:
Mild bilateral iliac disease. Patent common femorals bilaterally.
Moderate disease involving L SFA and popliteal and infrapopliteal vessels.
Svere disease invilving ostial R SFA with multiple areas of severe disease inolving the mid and distal R SFA, CTO R popliteal and multiple sveere stenoses involving R PT. Occluded R AT with patent R peroneal.
Interventions:
Crossing of CTO R popliteal
CSI R SFA and R Popliteal
PTA R SFA, R Popliteal and R PT
L Femoral and R PT Access
Procedure:
PCI procedure:
A 6F LIMA catheter was used to get access to the right common iliac and using a 0.035 Stiff angled glide into the right SFA, the catheter was replaced with a long Terumo sheath the tip of which was lodged in the right common femoral artery. RLE angiography was performed which revealed:
Initial Findings:
Mild bilateral iliac disease. Patent common femorals bilaterally.
Moderate disease involving L SFA and popliteal and infrapopliteal vessels.
Svere disease invilving ostial R SFA with multiple areas of severe disease inolving the mid and distal R SFA, CTO R popliteal and multiple severe stenoses involving R PT. Occluded R AT with patent R peroneal.
At this point access was obtained from the right PT artery under US guidance using aa 6F sheath. A 0.018 Confienza wire was used to navigate the CTO popliteal without success. Using a Gold tip Glide wire and a Quickcross catheter, the popliteal artery was crossed the the wire was replaced with a Viper wire. The R SFA and popliteal arteries were treated with CSI atherectomy with multiple passes. Then, the R PT was treated with a 2.0-2.5 EV3 Nanocross Elite baloon with multiple inflations at up to 16 atm. The R SFA was treated with a 4.0x250mm Armada Balloon at 10 atm. The popliteal and distal SFA were treated with a Lutonix 4.0x150mm DE balloon at 6 atm. Finally the distal popliteal was treated with a 3.5×40 mm EV3 balloon at 6 atm.
Final angiography revealed evidence of < 40% residual stenosis with a slight linear intimal dissection distally with no limitation of flow. There popliteal artery had < 30% residual stenosis and the PT had < 40% residual stenosis and there was excellent flow along the vessel..
Before Poplital PTA was performed, The PT sheath was removed, and hemostrasis was achieved using local pressure.. Finally the left femoral sheath was sutured in place then removed after the ACT was < 150.
The final ACT was 210. Intracoronary nitroglycerin was given during the procedure the maximize distal runoff and our ability to measure vessel size. The patient tolerated the procedure and left the catheter lab in stable condition.
Estimated Blood Loss: less than 30 mL
Specimens Collected: None
Complications: None; patient tolerated the procedure well.
Disposition: PACU – hemodynamically stable
Condition: stable
Moderate conscious sedation was administered by a qualified nursing professional under Continuous hemodynamic monitoring starting at 8:12 AM , and ending at 10:30 AM
Total IV Fentanyl: 200 mcg
Total IV Versed: 4 mg
Nurse:
Impression:
S/P successful recanalization of R popliteal and PTA of R SFA, Popliteal and PT arteries.
Treatment:
ASA
Brilinta
Beta Blocker
ACE/ARB
Statins
Continue current medical therapy
Thank you so much for the help!