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Subintimal angioplasty using 0.018 inch wire in the case of totally occluded and invisible route of infrapopliteal occlusion in the critical limb ischemia
- Operators: Seung-Whan Lee, MD, Jong-Young Lee, MD
Clinical Information
- Relevant clinical history and physical exam:
A 75-year old man admitted for Rt. foot great toe wound which showed gangrenous change. He has multiple co-morbidities such as long-term diabetes, hemodialysis on renal disease and diabetic retinopathy. (Foot 1, Foot 2)
- Relevant test results prior to catheterization:
The ABI (ankle-brachial index) showed very severe stenosis on both lower extremities. (Rt.0.45 / Lt.0.51). For the evaluation of vascular problem, Doppler ultrasound and CT angiography showed severe stenosis in Femoro-polpliteal transition and total occlusion of distal runoff vessels.
After discussion with multidisciplinary team, we decided to perform peripheral angioplasty.
- Relevant angiography findings:
The distal SFA to popliteal was severely stenosed and ATA and PTA were totally occluded with multiple bridge collateral. The circulation of foot was only dependent on the collateral flow. Fortunately the dorsalis pedis artery was seen. The target artery for wound by angiosome concept was ATA. The stump for the intervention was not seen. It is very difficult to guess the actual route of ATA. ( Movie 1, Movie 2, Movie 3).
Interventional Management
- Procedural step:
The Rt. 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 4.0x40 several times for the popliteal lesion. (Figure 1) For the strong backup support of procedure in the BTK lesion, the SHUTTLE TIBIALIS 4.0 Fr was advanced into the popliteal artery. 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. But, there was no definite stump for the advancement of the wire. We could not guess the route of the ATA. So, we planned to perform the subintimal angioplasty using the 0.018 inch peripheral artery dedicated V-18 300cm wire with the support of a balloon (Sleek 2.0X40). Fortunately using this wire, we made the small loop for the strong push and then advanced to the distal true lumen of the dorsalis pedis artery. We performed several balloon dilation using 2.0X40mm balloon. (Figure 2, Figure 3) The angiogram showed real route of the ATA. (Figure 4, Figure 5) We performed sequential balloon dilation using Sleek 2.0x220 and 2.5X220, several times. (Figure 6) Also, another ballooning using Symmetry 4.0X40mm was applied for the popliteal and distal SFA lesions. (Figure 7, Figure 8, Figure 9, Figure 10) The flow was dramatically improved. Final angiogram showed much better perfusion of the Rt. foot lesion compared with pre-procedural findings. (Figure 11, Figure 12, Movie 4) After this procedure, the patient underwent surgical debridement and wound was dramatically improved.
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