Case 2
A 67-year-old female with obesity, peripheral artery disease, and a history of coronary artery bypass surgery presents with ischemic rest pain (Rutherford category 5) and gangrene of the second toe. Duplex ultrasound and CTA show a flush occlusion of the SFA with poor collateral development and diffuse calcification extending to the P2 segment of the popliteal artery. The antegrade approach has been attempted previously and failed due to a hard proximal cap.
Discussion Points:
Discuss follow-up strategies to assess patency and optimize limb salvage outcomes, including medical therapy and lifestyle interventions.
Given the flush occlusion of the SFA, discuss the pros and cons of using cross over versus retrograde popliteal versus crural access.
Describe how you would use advanced guidewire techniques, such as the knuckle or loop technique, to navigate this challenging lesion.
If retrograde access is achieved, explain your strategy for integrating re-entry devices to restore intraluminal flow.
Discuss your escalation plan including vessel prep techniques.
Evaluate the potential risks of prolonged procedure time, including contrast volume, radiation exposure, and distal embolization.
Q1
Life style modification ( decrease BW – exercise- healthy food- decrease fat and carb – away of smoking )
Medication ( anti plt- statin- vasodilator-anticoagulant- control DM-control IHD )
Investigation : DUS
Clinical : progress of gangrene , degree and duration of rest pain, color and temp of foot
Q2
1-retry entry contralateral by cross over
2-Hybrid endarterectomy then sfa angioplasty
3-retrograde tibial access by low profile sets
Q3
Entry by loop of guide wire till cross lesion site then reentry into normal lumen by B back reentry device
Q4 Shock wave
EVL ballon
Chocolate ballon
Atherectomy devices ( orbital-rotational-laser )
Q5
Contrast ——- volume over load, nephropathy, git up set
Radiation ——- burn , cataract, cancer, fatigue
Circulation——- thrombosis especially if aptt not monitored
A(1):
To assess patency, follow up by arterial duplex U/S
Life style modifications, encourage walking, control of Diabetes and body weight reduction.
best medical treatment in form of antiplatelets, statins, vasodilators.
A(2):
The cross over technique is preferred for flush occlusion of SFA as it reduces access site complication, but it may be difficult in case of angulated aorta and difficult to reach infrapopliteal lesion.
Retrograde popliteal is done after failed antegrade approach, but has complications that may occur as hematoma formation post-intervention and difficulty for compression post-intervention.
Crural access I think is suitable here
A(3):
Using loop technique will help guide wire to pass subintimal in case of flush occlusion then renter using support catheter and reentery device into true lumen distal to the lesion.
A(4):
After retrograde access I will use re-entry device to pass from subintimal into true lumen.
A(5):
For vessel preparation in case of calcified vessels:
Special balloons as: PTA scoring balloon, chocolate PTA balloon.
Intravascular lithotripsywhich concluded IVL in combination with DCB showed better safety and durability in comparison to PTA + DCB for treating calcified vessels.
Atherectomy devices could be used but with caution to prevent distal embolization.
A(6):
Prolonged procedure time due to failure to cross lesion and I cease liability of vessel thrombosis so anticoagulant has to be used.
Prolonged exposure to radiation increase risk of skin rash and burn
Dye concentration and amount could cause CIN to the patient
A1 follow up plan no
control of risk factors like DM HTN and smoking
stick to best medical tratment
follow up duplex to assess patency amd CTA
A2 1st option is cross over
as there is flush sfa occlusion
so this access gives better pushability and good working distance
its limitaion acute aortic angle or AAA including bifurcation
not a better option if the patient has a tibial disease
retrograde pop is not a good option as the patient has disesed P2
and risk of pop fossa hemtoma
retrograde crural is a good option with a good success rate especially when using a microset and it also has less complication regarding hematoma or AVF
its limitaion may disrupt distal runoff
A3 using loop technique may be helpful in CTO as it usally psses subintimally and reentery can be done spontaneously or reentery device may be used
A4 we may use reentery device like beback to break the ateroma and do reentery but it needs experienced hands for the risk of perforation
A5 vessel prep
using scoring balloon or choclotate balloon
we may use intravascular lithotripsy in calcified vessels
aterectomy devices may be used also
A6 prolonged procedures has many risks as high radiation exposure
also high dose of contrast which may cause nephropathy
also multiple trails may lead to perforation or vessel thrombosis or distal embolisation
so better to abort after 3 working hours with failure to cross the lesion
Q(1):
To assess patency, follow up by arterial duplex U/S to assess restenosis, flow volume monthly then every 3 months.
Clinical examination by measuring ABPI.
Life style modifications, encourage walking, control of Diabetes and body weight reduction.
Pharmacological therapy: best medical treatment in form of antiplatelets, statins, vasodilators.
Q(2):
The cross over technique is preferred for flush occlusion of SFA as it reduces access site complication, but it may be difficult in case of angulated aorta and difficult to reach infrapopliteal lesion.
Retrograde popliteal is done after failed antegrade approach, but has complications that may occur as hematoma formation post-intervention and difficulty for compression post-intervention.
Crural access has higher potency rate, success rate, but takes longer time and if failed could cause major amputation.
Q(3):
Using loop technique will help guide wire to pass subintimal in case of flush occlusion then renter using support catheter and reentery device into true lumen distal to the lesion.
Q(4):
After retrograde access I will use re-entry device to pass from subintimal into true lumen.
Q(5):
For vessel preparation in case of calcified vessels:
Special balloons as: PTA scoring balloon, chocolate PTA balloon.
Intravascular lithotripsy: a study was done called (Disrupt PAD lll trial) which concluded IVL in combination with DCB showed better safety and durability in comparison to PTA + DCB for treating calcified vessels.
Atherectomy devices could be used but with caution to prevent distal embolization.
Q(6):
Prolonged procedure time due to failure to cross lesion and I cease liability of vessel thrombosis so anticoagulant has to be used.
Prolonged exposure to radiation increase risk of skin rash and burn
Dye concentration and amount could cause CIN to the patient.
A..1
Follow up post angioplasty include many points
First medications : asprin ,high dose statins and low dose revaroxiban for secondary prevention of adverse cardiovascular events
Second : life style modification as encouraging the patient to be active and avoid sedentary life . Advising the patient to practice exercise and to lose weight
Third : surveillance program to detect any early restenosis to deal with
Forth : Proper care of the foot and any wounds or infections
A2..
In a flush SFA occlusion the first option is contra lateral cross over access
It is more close to the lesion so it give us more support and better pushability for the wires and catheters
But in the same time cross over may be difficult in acute aortic bifurcation and if there is any other infrapoploteal lesion it becomes hard to deal with it from control lateral access
Popliteal retrograde access alis another option for lesion crossing if it is difficult to be crossed antigrade
Again if is close to flush SFA lesion especially if the distal cap is in favour of wire crossing (concave) it give more support
But access site control is a limitation of it’s choice as popliteal fossa hematoma may develop
Crural access is another option for retrograde crossing with reported high success rate but if it failed to cross the lesion it ends with amputation for CLTI patients
A3..
in such hard proximal cap the wire may fail to pass smoothly so some technics may be tried as loop technique as it give the wire more support and can help in crossing the lesion
A4..
If the wire fails to pass to the intraluminal plain I will use reentery devices to pass from the sub intimal plain to the intraluminal plain and care should be taken to get intraluminal access just above the lesion to avoid retrograde dissection of the CFA
A5..
After crossing the lesion . Vessel preparation together with DCP give good results vs PTA alone as fewer rate of stent use and more patency rate as mentioned in DISRUPT III trial
Vessel prep can be done by scoring balloones , IVL or Therectomy devices
A6..
Prolonged procedure time may be due to difficulty in crossing the lesion or complex and multilevel Arterial lesions so that prolongation encounter many hazards for the patient and the team prolonged procedure time means more exposure to radiation and it’s harmfull effect starting from skin rashand burn and ending In skin necrosis and cancer
Prolonged procedure time means more contrast useage and so more potential for developing CIN for the patient .
Also prolonged time may lead to distal thrombosis if care not taken for anticoagulation use and adjusting ACT
Q1:
follow up patency post operative with ABI and duplex assessment every 3 months for 1 year and follow up healing of the wound
post intervention anti platelet and low dose revarospire as post intervention medication and statins
life style modifications in the form of smoking cessation and good glycemic control and control of hypertension
Q2:
cross over pros treatment of any associated iliac lesion and and it works better in obese patients with large pannus and large diameter to deliver many tools may be needed during the intervention and it is nearer than the upper limb as another option for ante grade approach so more pushability and torquability
cons the hard proximal cap and being flash and there is no ostium to engage with
acute aortic bifurcation and difficulty to cross over
lossing the pushability and torquability if crural intervention was needed
Retrograde access of the popliteal is an option if no lesion was encountered in the pop artery but difficult control of the access site
Crural vessels being superficial in part of its course may be better and considered a second option if antegrade trial was failed
Q3:
first trial of the wire to pass intraluminal if faid with convex cap the looping the wire and passing subintimal would be an option till the area when reentry has to be done and has not to exceed this area
if failed an reentry device has to be tried
Q4:
outback as reentry device could be used
or use of double balloon (Rendezvous technique) to weaken the lesion
Q5:
in case of heavily calcification vessels intravascular lithotrepsy and DCB can be used
or using scoring balloon like chocolate balloon or using shock wave balloons
Q6:
prolongation of the procedure time and use of large amount of contrast which in turn predispose the patient to CIN and long time of exposure to radiation may predispose the patient and the staff to radiation induced inflammation ex dermatitis …
and long procedure time and multiple trials while tools are inside the vessel predispose to thrombosis and distal embolization
A1:
Follow up strategies include
Risk factors modification tight DM control weight reduction BMT in the form of COMPASS for cardiac protection foot care and wound healing follow up together with ABPI and DUS for serveillence of the revascularization procedure
A2:
Pros of crossover retrograde access is to pass the lesion antegrade which is the best and to avoid the complications of retrograde pop and crural access again it is prefered for the obese patient with CTO flush SFA lesion like our case
Cons of crossover technique is the limitations of tools with long shafts and difficult to target BTK vessels
Retrograde pop access in this case would be difficult as the lesion extends to P2 level so the puncture would be difficult and the hemostasis is challenging post procedure
Crural retrograde access with high patency and good results up to 96 % in case of failed antegrade access with some complications regarding vessel wall disruption with high amputation rate so the use of fluoroscopy and DUS guided puncture is prefered and the use of low profile tools is another disadvantage
A3:
Using the loop or knuckle tech will help in that long CTO lesion to get a subintimal track to pass the lesion with caution to the site of reentry to be just distal to the lesion
This tech needs a supporting catheter to advace the wire and re entry device could be used to re enter the lumen distally
A4:
In retrograde access re entery devices outback go back with low profile and sheathless advantages could be used or using targeting balloons at the re entry sites would help in guiding the wire to intraluminal then externalization through the proximal sheath
A5:
Vessel prep escalation strategy according to the study done by Steffanos 2023 concluded that Patient’s with infrainguinal moderate/severe calcification with challenging clinical decision making regarding the most optimal revascularization approach. Several specialty balloons have been developed to facilitate angioplasty with/without stenting and to lead to an optimal technical result.
The speciality balloons such as scoring balloons chocolate ballons shock wave IVL balloons
A6:
Prolonged procedure complications more than 3 hrs may lead to excessive exposure of the team and ptn him self to radiation that could lead to burn cancer cataract bony aches nausea vomitting (ARS)
Contrast indused nephropathy and encephalopathy
insitu thrombosis with distal embolization if the ACT is not followed up with caution and the ptn is not fully heparinized