Occluded instent left SFA stenosis | Fractured stents treated - Eluvia stenting

Case summary

• 49 Years old male
• Risk factors : HBP, smoker.
• Medical history : ischemic heart disease with PCI (LAD, RCA), lowerlimb artery disease with angioplasty (right iliac(2014 ASSURANT COBALT) and FSA (2010 MARIS), left FSA (2014 INNOVA) and popliteal artery (2014 PROMUS)).
• Clinical symptoms : intermittent claudication stage 2b
• Biological parameters : serum creatinine 8,2mg
• On going treatement : aspirin, ticagrelor, bisoprolol, ramipril, rosuvastatin.

Diagnostic images

This didactic procedure concerns a 49 years old man with a history of:

• Ischemic heart disease with PCI (LAD, RCA)
• Lower limb artery disease with multiple angioplasties: right iliac in 2014 (ASSURANT COBALT), right SFA in 2010 (MARIS), left SFA in 2014 (INNOVA) and right popliteal artery in 2014 (PROMUS).

Cardiovascular risk factors: Hypertension and smoking.

Actual treatments: Aspirin, Ticagrelor, Bisoprolol, Ramipril and Rosuvastatin.

He is presenting with severe left lower limb claudication with rest pain (stage3), (left > right). Several stents implanted on the left SFA 7 years ago.

The angiographic control showed bilateral long SFA occlusions with stent fractures on the left SFA stents, and a left CFA stenosis.

Educationnel Objectives

• Plan a step-by-step SFA occlusion revascularization through contralateral access.
• Materials choice: guidewires, support catheter, sheath, balloons and stents.
• How to manage contralateral access.
• Instent restenosis: Stent fracture.
• Discuss therapeutic options.
• Lesion preparation in instent restenosis cases.
• How to perform an Innova stent deployment?
• How to achieve a good positioning and post dilatation of the stent?
• Tips and tricks for managing multiple lesions on the same axis (CFA and SFA)
• What are adjunctive pharmacotherapies?

Step-by-step procedure: SFA instent occlusion revascularization

1. Access sites and cross over:

• Retrograde contralateral femoral access: Puncture under fluoroscopy with micro-puncture system, then a 6 French femoral sheath is positioned.
• Cross over with Reuter 5 French catheter and 0.035” GLIDEWIRE ADVANTAGE wire.
• Gentle crossing of the lesion of the left CFA stenosis.
• Exchange and advancing of a 6 Fr Flexor® introducer 45cm to the end of the left CFA
• Particular attention: The extremity of the introducer should be above the ostium of PFA for optimal imaging through collateral vascularization.

2. Recanalization:

• Support catheter Berenstein with 0.035” GLIDEWIRE ADVANTAGE advanced through the occlusion with knuckled tip.
• The wire position should be “instent” through the occlusion: orthogonal views is useful to confirm that position.
• Externalization of the wire distally: be sur that the wire is knuckled to avoid distal vessel perforation.

3. Predilatation

• Multiple predilatations of the fractured stents with a Mustang™ PTA Balloon 5*100mm.
• Multiple predilatations with a larger Mustang™ PTA Balloon 6*100mm at high pressure.
• Angiographic and fluoroscopic control of good stent expansion and antegrade flow.
• Careful positioning of the Stents covering the entry point of the occlusion and the distality of the occlusion.
• Stenting with Eluvia™ Drug-Eluting stent 6*150 mm, 7*150mm and 7*80mm.
• Post dilatation to ensure good stent apposition with Mustang™ PTA Balloon 6*100mm at high pressure.
• Angiographic control: checking for dissection and distal embolization.
• Flexion angiographic control: Knee flexion at 90°.

4. Treatment of the lesion of the left CFA

• Direct stenting of the short lesion of the left CFA with a balloon expandable stent 7*18mm sized 1:1 with the artery with no over expansion to avoid dissection.
• Angiographic control

•  10)Medical adjunctive treatments
• Pre-procedural: Heparin and mild sedation.
• Post procedural: The patient is already under Aspirin, Ticagrelor and high statin dose for his ischemic heart disease.

Bibliography

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