|Subintimal angioplasty using 0.018 inch wire of infrapopliteal occlusions in critically ischemic limb|
|- Operators: Seung-Whan Lee, MD, Jong-Young Lee, MD|
|- Relevant clinical history and physical exam:
A 56-year old woman admitted for both foot wounds which showed gangrenous change, especially in Rt. foot. She has multiple co-morbidities such as long-term diabetes, hemodialysis on renal disease and diabetic retinopathy. About 20 days ago, patient has been suffered from the febrile sensation, abrupt swelling and color change of both limbs. (Foot 1, Foot 2)
- Relevant test results prior to catheterization:
The ABI (ankle-brachial index) showed very severe stenosis on both lower extremities. (Rt.0.59 / Lt.0.47) The tissue oxygenation unit was 11.60 (pO2) at Rt. and 13.31 (pO2) at Lt. foot.
Rt. foot lesion was so severe and the nuclear study showed osteomyelitis. After discussion with multidisciplinary team, we performed the BK amputation.
- Relevant angiography findings:
The distal SFA was totally occluded and reconstructed the popliteal artery. And the ATA, PTA and peroneal were totally occluded and only distal run-off vessel of ATA was visible. The target artery for wound was fortunately ATA. ( Movie 1, Movie 2, Figure 0, Figure 1, Figure 2, Figure 3).
|- Procedural step:
The Lt. femoral artery was punctured with 6 Fr Sheath using antegrade approach. The 0.032 Terumo wire successfully advanced into the totally occluded segment and then we performed balloon angioplasty using POWERFLEX 5.0x60 several times. (Figure 4) For the strong backup support of procedure in the BTK lesion, the SHUTTLE TIBIALIS 4.0 Fr was advanced into the popliteal artery.(Figure 5) The 0.014 inch Choice-PT II guide wire (182cm length) with Corsair channel dilator system was tried to negotiate the totally occluded ATA lesion. The wire could pass the lesion because of heavy calcification, so we changed to the Miracle 3.0g stiff wire and then Conquest Pro stiff wire, sequentially but both wires could not go into the distal lumen, at all. (Figure 6, Figure 7, Figure 8) We planned to perform the subintimal angioplasty using the 0.018 inch peripheral artery dedicated V-18 300cm wire with the support of a Corsair microcatheter. Using this wire, we made the small loop for the strong push and then advanced to the distal true lumen. (Figure 9, Figure 10) After advance of microcatheter, the selective angiogram showed successful re-penetration of the distal true lumen. (Figure 11) We performed sequential balloon dilation using Sleek 2.0x220 and 2.5X220, several times. (Figure 12, Figure 13, Figure 14, Figure 15) A self-expandable SMART-CONTROL stent 6.0x120 was implanted for the distal SFA lesion due to severe dissection and haziness even after balloon dilatation. The flow was dramatically improved. (Figure 16) Final angiogram showed much better perfusion of the Lt. foot lesion compared with pre-procedural findings. (Figure 17, Figure 18) After this procedure, the patient underwent surgical debridement and wound was dramatically improved.