Recanalization for limb salvage. Three occlusions: femoral, popliteal and posterior tibial arteries

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Recanalization for limb salvage. Three occlusions: femoral, popliteal and posterior tibial arteries

Case of the month: December 2017

This 18 minutes didactic procedure concerns a 78 years old male with extremely severe peripheral artery disease: a Left limb amputation and a Right limb trophic ulcer. He presents Three right consecutive artery occlusions: Mid-SFA, Popliteal, proximal and distal posterior tibial.

This extremely complex case was treated using different technics according to the arterial segment: Sub intimal angioplasty and long stenting for SFA, Drug coated balloon for Popliteal, DES for proximal posterior tibial and coronary technics for plantar arteries.

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Step-by-Step Procedure

Right Antegrade femoral access
Pre-procedure discussion of strategy for a multilevel artery occlusion
Guide wire selection and escalation for crossing
Support micro-catheter selection
Pre-dilatation of more than 50cm with low profile long balloon
Technics to re--enter in foot arteries
DES for distal leg arteries
DCB for popliteal artery
Self-expandable drug eluting stent for dissection and residual stenosis of SFA

Learning points

Selection and feasibility of antegrade femoral access
Guide Wire and micro-catheter selection for multilevel crossing
Balloon angioplasty with low profile long balloons
Technics to re-enter in plantar artery
Use of DCB (Drug Coated Balloon) for popliteal artery
Use of balloon DES in tibial artery
Self -expandable DES at the femoral level

Biobliography

Short-Term Results of Eluvia™ Paclitaxel-Eluting Stent in External Iliac and Femoropopliteal Lesions - Article
Elens M, Verhelst R, Possoz J, Mastrobuoni S, Lacroix V, Astarci P.
Surg Technol Int. 2017 Nov 9;31. pii: sti31/894. [Epub ahead of print]

Drug-coated balloon angioplasty for the management of recurring infrapopliteal disease in diabetic patients with critical limb ischemia - Article
Palena LM, Diaz-Sandoval LJ, Gòmez Jabalera E, Peypoch Perez O, Sultato E, Brigato C, Brocco E, Manzi M.
Cardiovasc Revasc Med. 2017 Jun 20. pii: S1553-8389(17)30196-3. doi: 10.1016/j.carrev.2017.06.006. [Epub ahead of print]

Innovations in the Endovascular Management of Critical Limb Ischemia: Retrograde Tibiopedal Access and Advanced Percutaneous Techniques - Article
Mustapha JA, Diaz-Sandoval LJ, Saab F.
Curr Cardiol Rep. 2017 Aug;19(8):68. doi: 10.1007/s11886-017-0879-1.

Innovations in the Endovascular Management of Critical Limb Ischemia: Retrograde Tibiopedal Access and Advanced Percutaneous Techniques - Article
Mustapha JA, Diaz-Sandoval LJ, Saab F.
Curr Cardiol Rep. 2017 Aug;19(8):68. doi: 10.1007/s11886-017-0879-1.
Angiosome-directed revascularization in patients with critical limb ischemia - Article
Jongsma H, Bekken JA, Akkersdijk GP, Hoeks SE, Verhagen HJ, Fioole B.
J Vasc Surg. 2017 Apr;65(4):1208-1219.e1. doi: 10.1016/j.jvs.2016.10.100.

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