Cath Lab Digest

author affiliations:

From the Department of Cardiology, St. Luke’s Medical Center, and the University of Arizona College of Medicine, Phoenix, Arizona.

The author reports no conflicts of interest regarding the content herein.

Manuscript submitted February 10, 2009, provisional acceptance given February 19, 2009, and final version accepted February 23, 2009.

Address for correspondence: Richard R. Heuser, MD, FACC, FACP, FESC, FASCI, Director of Cardiology, St. Luke’s Medical Center, Clinical Professor of Medicine, University of Arizona College of Medicine, 1331 N. 7th Street, Suite 400, Phoenix, AZ 85006. E-mail: rheuser@affcard.com

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Abstract

Acute thromboembolic events can occur in percutaneous peripheral interventions. We present a case of periprocedural acute limb ischemia due to embolic thrombosis of the right tibioperoneal trunk during percutaneous transluminal angioplasty and stenting of the external iliac artery, with final resolution using an over-the-wire balloon in a Fogarty-type manner.

Introduction

Thromboembolic complications of periprocedural peripheral percutaneous transluminal angioplasty (PTA) and/or stenting can occur and lead to acute limb ischemia (ALI) that requires prompt intervention. Treatment can include thrombolytic infusion, surgical bypass or endovascular treatment. We present a case of periprocedural thromboembolic ALI to the tibioperoneal trunk after PTA and stenting of the right common and external iliac artery, successfully treated with a percutaneous Fogarty-type method using an over-the-wire (OTW) balloon.

Case Report

A 64-year-old male with a history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease, and known prior peripheral arterial disease (PAD) requiring bilateral common iliac arterial stents presented with worsening right leg claudication at less than one-block distance with ambulation, despite smoking cessation, antiplatelet therapy and a trial exercise regimen. His right lower-extremity ankle-brachial index (ABI) was 0.47 with nonpalpable distal foot pulses. Peripheral angiography of his right leg was performed via a contralateral approach. We placed a Contra-2 catheter (Boston Scientific Corp., Natick, Massachusetts) through a 6 Fr sheath catheter, gaining entrance from the left iliac artery to the right iliac artery. The peripheral angiogram of his right lower extremity showed 100% in-stent restenosis of the right common and external iliac artery distal to the common iliac stent with collateral reconstitution in the proximal right superficial femoral artery (SFA) (Figure 1). Next, the Contra-2 catheter was exchanged using a Glidewire (Terumo Medical Corp., Somerset, New Jersey) in order to cross the lesion, then exchanged for an Ansel sheath (Cook, Inc., Bloomington, Indiana) in preparation for PTA and stenting. A 6.0 x 60 mm Vascular Fox balloon (Abbott Vascular, Redwood City, California) was used to dilate the lesion, followed by stenting with a 7.0 x 120 mm, overlapping proximally with an 8.0 x 60 mm Xceed Biliary self-expanding stent (Abbott Vascular), and finally, post-stent balloon dilation was performed using an 8.0 x 80 mm Vascular Fox balloon (Figure 2). Angiography at this time showed no flow beyond the tibioperoneal trunk, suggestive of distal embolization of atherosclerotic debris, although no visible thrombus could be visualized (Figure 3). During this period, the patient had already been on aspirin and clopidogrel (Plavix, Bristol-Myers Squibb/Sanofi Pharmaceuticals, Bridgewater, New Jersey), given intravenous heparin sodium (Baxter Healthcare Corp., Deerfield, Illinois) prior to the start of peripheral intervention. Eptifibatide (Integrilin, Millennium Pharmaceuticals, Schering Corp., Kenilworth, New Jersey) bolus and infusion was added at this time. Several passes with the Pronto extraction catheter (Vascular Solutions, Inc., Minneapolis, Minnesota) were completed, but unsuccessful. Following this, we placed a 5.0 mm EPI filter (Boston Scientific) device just distal to the right tibioperoneal trunk to attempt to capture any debris. This was also unsuccessful. Then several passes with the AngioJet Rheolytic Thrombectomy System (Possis Medical, Inc., Minneapolis, Minnesota) were completed. Again, this was unsuccessful, with continued no-flow distal to the tibioperoneal trunk. Several 300 µg doses of intravascular nitroglycerin given through a Glidecatheter (Terumo) also failed to restore blood flow distal to the tibioperoneal trunk. As a last resort, a 2.0 x 12 mm over-the-wire Voyager balloon (Abbott Vascular) was used in a Fogarty-type manner by placing it just distal to the tibioperoneal trunk. We used a low balloon inflation to 8 atm and pulled proximally into the right SFA and finally into the right common femoral artery. Used in a Fogarty-type thrombectomy manner, it resulted in immediate two-vessel runoff below the knee (Figure 4). The patient’s symptoms of right leg pain resolved and eptifibatide infusion was continued for 18 hours post procedure. We repeated the peripheral angiogram 24 hours later and confirmed two-vessel runoff below the right knee.

Discussion