Richard R. Heuser, MD, St. Luke’s Medical Center
Eddie Lipan, MD, Tempe St. Luke’s Wound Care Center
Disclosure: Dr. Heuser reports equity in Radius Medical.
The authors can be contacted at firstname.lastname@example.org
A 63-year-old male smoker presented with critical limb ischemia of his left foot. Four years prior, the patient underwent a right femoral-popliteal (fem-pop) bypass after failed intervention on his right leg. He ended up losing his fifth digit on his right foot. Three years prior to his visit, he underwent a fem-pop procedure on his left leg for severe claudication after failed intervention. One year later, he underwent a redo fem-pop on his left leg with a cadaveric vein. Twelve months prior to the visit, a self-expanding stent was placed in the fem-pop graft because of continued foot ischemia. Seven months prior to his visit, his symptoms re-occurred and the patient was told nothing could be done after an angiogram showed the vessel was occluded. The patient suffered from polyneuropathy and was unable to walk, but did not want amputation. He was on cilastazol and coumadin, and has type II diabetes. Exam revealed the left foot was cool and red, but there were no ulcers. Capillary filling was adequate. His right dorsalis pedis was normal and he had no popliteal pulse on either side and no left pedal pulses. A contralateral approach was utilized and revealed the graft to be occluded on the left side (Figure 1, Video 1).
Figure 1, below: There is a bud of the occluded fem-pop graft visualized.
It was clear that the patient very likely had thrombus in the graft, and it was felt that a laser would be appropriate either in the traditional manner or using the step-by-step method. Whenever we use the step-by-step method, we feel a need to make sure we are centered, so we recommend using the CrossLock LP device (Radius Medical). In this case, we used the CrossLock LP which is usually utilized for infrapopliteal lesions, but it was felt that the 3 mm elastomeric balloon would fit well into the nub of the bypass graft (Figure A) (Figures 2-4).
Figure A, below: The CrossLock LP, similar to the CrossLock in that it has a 6 French (F) outer diameter compatible with 6F sheaths. The CrossLock LP has a 3 mm in diameter elastomeric balloon at the tip.
Figure 2, below: This angle reveals the origin of the total occlusion.
Figure 3, below: There is a hint of 2-vessel delayed filling noted near the ankle.
Figure 4, below: The CrossLock LP is inflated at the site of the total occlusion.
Using the CrossLock LP, we immediately subtended the bypass graft all the way down and then we were able to get access into the infrapopliteal vessels (Figures 5-6).
Figure 5, below: The CrossLock LP centers the position of the catheter to allow immediate recanalization of the occluded graft. It was imperative to not get extra luminal with placement of the wire.
Figure 6, below: Further passage of the Command wire.
We performed .9 laser atherectomy (Spectranetics) in the graft and then performed balloon angioplasty (Figures 7-8).
Figure 7, below: The anastomosis is seen with 2-vessel runoff and some intragraft stenosis.
Figure 8, below: The vessel is patent after recanalization. There is distal anastomotic disease.
Two Xience (Abbott Vascular) stents, a 4.0 and 3.5cm at the anastomosis site, were placed and because of residual stenosis at the popliteal, we placed a 5.5cm Supera (Abbott Vascular) stent. At the end of the procedure, because of multiple failures of the graft, we then covered the graft with a 6.0 mm x 250 mm Gore Viabahn (W.L. Gore & Associates) stent graft. Final angiography demonstrated brisk 2-vessel runoff (Figures 9-10).
Figure 9, below: This angiogram is performed after placement of the Gore stent graft and the Supera popliteal stent.
Figure 10, below: Angiography following placement of 2 coronary stents just distal to the anastomosis. Now there is 2-vessel runoff and excellent flow.
Case #1 Discussion
With the likelihood of thrombus present in a patient suffering issues with fem-pop graft patency, we felt it was imperative to remove thrombus. The utility of the CrossLock LP combined with laser atherectomy made it possible for us to ablate with successful recanalization without the necessity of using an intragraft, prolonged tPA infusion. The fluoroscopic time was long at 73 minutes and contrast utilization was 236ml.
A 90-year-old woman presented with critical limb ischemia of her left foot. She suffered from claudication beginning 12 years ago. Six months prior, she developed an ulcer on her foot and shortly thereafter underwent femoral popliteal bypass. Her symptoms recurred and repeat fem-pop surgery was performed at that time. It immediately failed and she had a cadaveric vein placed as a fem-pop conduit. This again occluded and after two revisions of the fem-pop bypass, she was told five months prior that she would not be able to have any further intervention on her leg; it was suggested she just go to hospice. A medial 1 cm x 6 cm foot ulcer was noted on examination, but the patient refused any intervention. Six weeks later, with insistence from the wound care center, and with the patient’s second and third digit now black on that foot, she now allowed us to see her for possible limb salvage. Exam showed a cool foot and bluish black second, third and fourth digits. No pedal pulses were present. We approached the patient via the contralateral groin and angiography revealed her native superficial femoral artery and graft were occluded at the origin (Figures 11-12).
Figure 11, below: The contralateral injection shows the subtotal common femoral artery stenosis and the totally occluded fem-pop graft (middle vessel). The lateral vessel we believe was the patient’s native superficial femoral artery. The medial vessel is the deep femoral artery.
With the thought that there was the likelihood of thrombus in the vessel, we again utilized the CrossLock LP and as in the previous case, immediately crossed the occlusion down to the tibial vessels with a Command wire (Abbott Vascular) (Figures 13-15).
Figure 13, below: The CrossLock LP is inflated in the occluded graft.
Figure 14, below: The passage of the wire.
Figure 15, below: The entire graft was crossed into the digital arteries.
With some suggestion of thrombus in the digital arteries, we administered 3mg of tPA locally (Figures 16-17).
Figure 16, below: The digital arteries are patent, but there is a question of the presence of thrombus.
Figure 17, below: Magnified view. Injection through a FineCross catheter.
A .9 laser was used and subsequent balloon angioplasty was performed using embolic protection (Figures 18-19).
Figure 18, below: An angiogram of the proximal portion of the graft after recanalization.
Figure 19, below: An angiogram of the mid graft.
The fluoroscopic time was 25.2 minutes and contrast was 273cc. At the end of the procedure, the patient had 2-vessel infrapopliteal flow. Several hours later, the patient was seen by the orthopedic surgeon for metatarsal surgery. The surgeon stated that all the toes were now pink and the patient had palpable pedal pulses, and although it is very likely that some amount of amputation may be necessary in the second and third toe, nothing needs to be done at this time, and the patient was discharged the next day.
Case #2 Discussion
In the case of this lady who most likely had thrombus present, centering was essential, as was laser and the use of a embolic protection filter. We were very hesitant to subject a 90-year-old woman to a prolonged tPA infusion.
In both cases, patients who have been told nothing can be done still may have options to not only revascularize, but salvage, previously unsuccessful fem-pop grafts.