Below The Knee Intervention using Triple kissing ballooning technique

- Operator : Nakamura Shigeru

Below The Knee Intervention using Triple kissing ballooning technique
- Operators: Nakamura Shigeru, MD, Seung-Whan, Lee, MD
Clinical Information

- Relevant clinical history and physical exam:
The patient was a 75-year old man with who admitted for toe wounds. He had multiple co-morbidities such as dialysis on renal disease, old stroke, and graft interposition due to AAA. He was diagnosed with peripheral artery disease by peripheral CT angiography at another hospital. He visited our hospital for proper management.

- Relevant test results prior to catheterization:
The 3D-CT angiography showed multifocal, mild to moderate degree of stenosis in Rt.SFA. The ABI value was 0.90 at Right and 1.0 at Left side, respectively.

- Relevant angiography findings:
There were diffuse, multiple spontaneously ruptured stenoses at the trifurcation site in the below knee area but the proximal portion of arterial system in right lower limb was relatively healthy (Figure 1, Figure 2, Figure 3, Figure 4).

Interventional Management

- Procedural step:
The femoral artery was punctured with 7 Fr Sheath using antegrade approach. The 0.014 inch Choice-PT II guidewire (182cm length) with JAMIRO 2Fr microcatheter system was inserted into Rt. Posterior tibial artery and then balloon angioplasty using Ultra Thin (Symmetry 2.5 x 40) was performed. (Figure 5) As next step, We inserted 0.014 inch another Choice-PT II wire into anterior tibial artery and then balloon angioplasty with MAXI 2.0 x 60 mm was performed. (Figure 6) And then. We tried to advance the peroneal artery with Fielder FC and Fielder XT, sequentially using JAMIRO catheter. (Figure 7) After wire crossing, MAXI 2.0 x 60mm balloon dilatation was performed. (Figure 8) Finally, we performed triple kissing ballooning dilatation using Ultra Thin Symmetry 2.5X40 upto 4 atm in anterior tibial artery , MAXI 2.0X60 upto 4 atm in peroneal artery and SAVY 4.0X40 upto 4 atm in popliteal artery. (Figure 9, Figure 10, Figure 11) The final results were good. (Figure 12, Figure 13)

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