TPA Works Well When Administered in the Clot

A 43-year-old female presented with a 2 cm x 3 cm non-healing ulcer for 3 months on the dorsal of her foot. She was sent over from the wound care clinic. She was a non-smoker, non-diabetic woman with anorexia nervosa and protein C deficiency.

The patient’s primary care internist referred her to a vascular surgeon a month ago. He couldn’t cross her CTO and infused TPA x 52 H and still couldn't cross it. He told her to exercise and encouraged her to come back if her claudication worsened. The wound still did not heal and she continued to have resting claudication.

Figure 1. The angiogram was performed using the contralateral approach. Notice there is an occlusion just after 2 large collateral branches.




Figure 2. The popliteal vessel was not well seen.





Figure 3. Infrapopliteal vessels were sparse.





Figure 4. A 5 Fr Wildcat (Avinger) somewhat easily crossed the total occlusion.




Figure 5. Although it was easy to cross the CTO at the popliteal site while passing the Wildcat, it became hung up. We could not either advance it or retract it. Finally, with a fair amount of force on the Wildcat and 6 Fr contralateral sheath, we were able to remove the catheter.



Figure 6. When I pulled the catheter back, the angiogram showed that we had adequately recanalized the CTO. So, in spite of this clear dissection, we proceeded and crossed carefully passed the original occlusion with a .014 Whisper wire (Abbott Vascular).



Figure 7. After balloon dilation (AngioScore), there was complete resolution of the total occlusion with excellent 2-vessel run off and complete resolution of the dissection.





Within a week of recanalization of her CTO, there has already been an improvement in healing of the lesion. If you look at Figure 1, I suspect the vascular surgeon never delivered any TPA to the total occlusion and the drug was simply infused in the collateral branches. Utilizing the Wildcat, even resistant and recalcitrant CTOs have been able to cross fairly easily. Clearly, however, the stiff probe became embedded into calcific plaque. Luckily, we were able to remove the probe without any significant permanent arterial trauma.

Coauthors: Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI and Timothy J. Kieborz, DO

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