A 60-year-old white man had had a severe left lower extremity vascular compromise with rest pain at night. He had had prior left common iliac artery occlusion and had undergone right common iliac angioplasty and stenting, and a right-to-left femoral-femoral crossover graft with endarterectomy of the left common femoral and proximal left superficial femoral artery (SFA).1 He initially had done well with this strategy, but recurrent problems led to redo surgery, owing to vascular compromise. He had also been found to have developed thrombosis of the femoral-femoral bypass graft and evidence of infection.
At that point, he had placement of a vein graft with removal of the femoral-femoral bypass. Unfortunately, this graft thrombosed and the patient underwent Fogarty thrombectomy with improvement.2 He had subsequent evidence of inflammatory changes, was treated for infection, and then had ongoing antibiotic suppression therapy.
His medications included atorvastatin 40 mg/day, apixaban 5 mg twice daily, cefuroxime 250 mg/day hydrochlorothiazide 12.5 mg/day, and lisinopril 10 mg/day.
On exam, blood pressure was 144/80 mm Hg and pulse was 68. Cardiopulmonary exam was unremarkable; however, there was an intact right-to-left femoral-femoral bypass with the graft inserting into the lower part of the left SFA and diminished left lower extremity pulses.
Computed tomography (CT) angiography evidenced patency of the previously placed right common iliac stent. The right external iliac artery was patent and the left external iliac artery was occluded. The right common femoral and deep femoral on the right were not visualized well, owing to surgical clips, but the right SFA was widely patent. The right-to-left femoral bypass was not well visualized at its origin, but it was without obvious visual stenosis. The distal limb extended into the medial aspect of the left leg, with an anastomosis with the distal left SFA. The anastomotic site was felt to harbor a moderately high-grade stenosis. There was disease distal to the anastomosis, but the popliteal was patent and reconstituted above the knee with three-vessel runoff.
The patient underwent angiography that was performed through the crossover graft. The graft had been entered with a micropuncture technique and a 6 French Glide sheath (Terumo) had been placed. The graft was widely patent, but there was occlusion of the distal anastomotic site with perhaps some thrombus at this site (Figure 1). A Finecross microcatheter (Terumo) and a Balance Middleweight (BMW) .014-inch universal wire (Abbott Vascular) was placed, and was able to traverse into the left SFA. However, a Miracle Bros 6 wire (Asahi Intecc) was required to reach the popliteal through the total occlusion of left SFA. The system was replaced with a Spartacore 300 .014-inch wire (Abbott Vascular), a TrailBlazer 90 catheter (Medtronic), and then a Glidewire straight stiff wire (Terumo) for further advancement into the popliteal artery. The TrailBlazer was removed for an angled Glidecath catheter (Terumo) and finally, a straight stiff Glidewire was able to be placed into the left popliteal artery. We ascertained that we were in the true lumen by using injections through the guide catheter. A long Rosen wire (Cook Medical) was placed down the distal popliteal and the microcatheter was replaced with an EverCross 4 mm x 100 mm x 135 mm balloon (Medtronic) that was inflated to 10 atmospheres (atm) for 16 seconds, followed by overlapping inflations from distal to proximal at 8 atm for 14 seconds, 8 atm for 10 seconds, 8 atm for 15 seconds, 10 atm for 11 seconds, and 10 atm for 13 seconds. We then performed angiography. The balloon was removed and replaced with a Zilver PTX 6 mm x 120 mm stent (Cook Medical) in the distal aspect of the SFA, then was more proximally overlapped with a 7 mm x 120 mm Zilver PTX stent, and even more proximally with a 7 mm x 60 mm Zilver PTX stent. The stents were initially post-dilated with a 5 mm x 150 mm EverCross balloon distally, which was then exchanged for a 6 mm x 200 mm EverCross balloon, dilated to 8 atm for 45 seconds, proximally. Completion angiography showed three-vessel runoff to the foot with what appeared to be improved collateral filling of the posterior tibials, with moderate residual disease of the anterior tibial artery (Figures 2A-C). The Glide sheath in the femoral-femoral graft was removed and local hemostasis was obtained with firm digital pressure.
Unfortunately, the patient began to experience left lower extremity claudication symptoms anew, sixteen months after the aforementioned intervention. Peripheral angiography revealed a recurrent left SFA occlusion (Figure 3). It was addressed with drug-eluting balloon angioplasty (IN.PACT Admiral 6.0 mm x 250 mm [Medtronic]) (Figure 4), with a good angiographic result and ongoing relief of claudication symptoms. The patient was treated with antiplatelet therapy with aspirin 81 mg daily, clopidogrel 75 mg daily, and also rivaroxaban 2.5 mg twice daily, indefinitely, with the last medication added based on the data from the COMPASS trial3. However, triple-drug therapy, which we felt prudent to employ early post redo interventional procedure, was likely to increase hemorrhagic diathesis post procedurally, and was not the approach prospectively evaluated in the COMPASS trial. Thus far, three months after the above redo intervention, the patient is without recurrent claudication symptoms.
This case adds insight into the benefit of complementary endovascular technologies with difficult vascular surgery to improve outcomes in complex peripheral vascular disease. However, it should be recognized that these patients have a high incidence of recurrences. It may be that optimization of medical therapy in addition to interventional therapy will improve long-term outcomes for these complex patients.
1Clinical Professor, California Northstate University College of Medicine
Disclosures: Dr. Scott Baron reports he is on the speakers bureau for Abbott. Dr. Arvin Arthur and Mohammed Nazir, RCIS, report no conflicts of interest regarding the content herein.
Dr. Baron can be contacted at firstname.lastname@example.org.
- Lee CJ, Morasch MD. Femorofemoral (femoral-femoral) bypass technique. Medscape. August 14, 2018. Available online at https://emedicine.medscape.com/article/1830260-overview. Accessed July 15, 2019.
- Handa R, Sharma S, Handa R. Vascular graft failure of leg arterial bypasses - a review. Journal of Hypertension and Cardiology. October 8, 2014. Available online at https://openaccesspub.org/jhc/article/114. Accessed July 15, 2019.
- Anand SS, Bosch J, Eikelboom JW, et al; COMPASS Investigators. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomized, double-blind, placebo-controlled trial. Lancet. 2018 Jan 20; 391(10117): 219-229. doi: 10.1016/S0140-6736(17)32409-1.