PREOPERATIVE DIAGNOSES:
1. Rutherford class IV claudication with ABI on the left of 0.47.
2. Asymptomatic carotid disease.
HISTORY: This very pleasant 69-year-old white male with past medical
history significant for peripheral arterial disease in the form of
asymptomatic carotid stenosis who reports that he has had pain in his left
leg for some time that has now become started to come on at rest. The pain
is in his foot in the left calf and he does have rest pains with this. ABIs
were performed that showed ABI of 0.47 in the left leg. He is on aspirin
and statin therapy. He does not smoke and as such invasive peripheral
angiography was performed with possible intervention.
PROCEDURES:
1. Aortogram with runoff.
2. Failed ipsilateral retrograde recannulation of a common iliac stenosis.
DESCRIPTION OF THE PROCEDURE: The patient was brought to the cardiac
catheterization lab after informed written consent was obtained. He was
prepped and draped in the usual sterile fashion with special attention to
the right and left groin. The patient was sedated with Versed and fentanyl,
and using ultrasound guidance, fluoroscopic guidance and micropuncture,
right femoral artery access was obtained with one front wall puncture under
ultrasound guidance and a 5-French femoral sheath was inserted. An
Omniflush was inserted into the right femoral artery and advanced to the
infrarenal abdominal aorta and digital subtraction angiography was
performed. A left common iliac occlusion that was rather short nature was
identified and as such intervention was attempted. Using ultrasound
guidance and micropuncture, a left femoral arterial access was obtained and
a 6-French sheath was inserted using standard technique. Next, a Glidewire
and a Seeker catheter were used to try to in retrograde fashion recannulate
the CTO of the left common femoral; however, we got in the subintimal tract
and the procedure was aborted. Digital subtraction angiography at the end
of the procedure showed that all branch vessels that were previously present
were still accounted for. There was good collateral flow to the left common femoral artery
and the right common iliac and infrarenal aorta were intact
and unchanged from previous. Manual 20 mg of protamine were given to
reverse heparin. Manual pressure was held on the right 5-French common
femoral arteriotomy site until hemostasis was obtained and the left was
successfully Perclose. The patient exited the peripheral vascular lab in
stable condition with no immediate complications.
FINDINGS:
1. Infrarenal abdominal aorta, that is moderately calcified, but patent
with moderate stenosis.
2. The right common iliac has moderate diffuse disease, but is patent.
3. The right internal iliac is patent with moderate disease.
4. The right external iliac is patent with moderate disease.
5. The right common femoral is patent with moderate disease.
6. The left common iliac is occluded. There is a small stump proximally
and there is approximately 7 to 8 cm occlusion which then reconstitutes via
collaterals into the external and internal iliac arteries which are patent
with moderate disease.
ASSESSMENT:
1. Occluded left common iliac with small proximal stump off of the aorta,
failed retrograde ipsilateral recannulization.
2. Otherwise, moderate peripheral arterial disease.
3. Successful StarClose of the left femoral arteriotomy and manual pressure
right femoral arteriotomy.