Cath Lab Digest

This is a case of a 52-year-old man who presented to our practice requesting paperwork be filled out for his disability claim. He had been diagnosed with PVD 2 years prior. He was found to have a totally occluded proximal right SFA about 10 mm distal to the profundus origin. He was referred for a femoropopliteal bypass surgery. One month after the surgery he had a recurrence of symptoms. He was unable to walk 50 feet without severe claudication. He was then told that nothing further could be done and his medical therapy was optimized with little effect. Eleven months later, he presented to Phoenix Heart Center for the above referenced paperwork. ABI’s were repeated and were documented to be 0.3 on the right leg and normal on the left leg. After much discussion and education, he was convinced that another angiogram with intent to intervene was reasonable prior to applying for disability.

A repeat angiogram was performed and this showed the same complete occlusion just below the origin of the profunda artery. There was reconstitution at the level of the adductor canal. Normal 3-vessel runoff was demonstrated. Using a contralateral approach, a 6 Fr Ansel sheath was advanced to the ostium of the right superficial femoral artery. We then advanced a Big-Boss catheter (BridgePoint Medical) over a Miracle Bro 3 (Asahi, Abbott Vascular) wire for back up. The Big-Boss catheter advanced from the true lumen through the totally occluded segment without much difficulty. When the catheter was nearing the distal cap we advanced the Miracle-Bro 3 wire through the cap into the popliteal artery. Angiography demonstrated that the wire was in the distal true lumen. Because the appearance of the proximal cap showed there was possible thrombus, we decided to proceed with a Pathway catheter. This catheter was advanced with the blades down initially and additional passes were made with the blades up. There was considerable resistance to passage in the mid-SFA. An angiogram showed some fibrous appearing plaque after the Pathway catheter was removed. PTA was performed with a 100 mm long balloon (AngioSculpt) the whole length of the SFA. This resulted in an excellent angiographic result with approximately a 20% residual lesion in the mid SFA. The patient is now enrolled in an exercise program and remains asymptomatic. Needless to say he withdrew his application for disability and has returned to work.

Perhaps we are all too willing to say that nothing can be done, and we dare not challenge difficult or seemingly impossible cases (not that this case was difficult or impossible). But if we do not try then we cannot state for certain that nothing can be done to fix the problem.

Figure 1. Pre proximal.

Figure 2. Pre distal.

Figure 3. BridgePoint.

Figure 4. Pathway.

Figure 5. Post Pathway.

Figure 6. AngioSculpt.

Figure 7. Post proximal.

Figure 8. Post distal.