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Case presentation: Critical Limb Ischemia

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1 Case presentation: Critical Limb Ischemia
Strategies on the Frontline Case presentation: Critical Limb Ischemia Subhash Banerjee, MD VA North Texas Health Care & UT Southwestern Med. Ctr. Dallas, TX

2 Case presentation 77 year old diabetic male Veteran with presents with c/o a “deep sensation of pain” in his right calf Partial relief is often obtained by taking a short walk around the room Right coronary artery PCI 6 months ago Continues to smoke cigarettes ABI: 0.5 (B/L); ankle pressure 52 mm Hg

3 Diagnostic angiographic images

4 Diagnostic angiographic images

5 Initial unsuccessful attempt
Contralateral CFA access 6F Crossover sheath Primary GW/support catheter crossing Question: Access options: contralateral, antegrade or retrograde pedal? Crossing strategy: wire-catheter approach versus dedicated CTO crossing device strategy Escalation of symptoms after failed attempt

6 Repeat attempt in 4 weeks
Antegrade access with 6F 45 cm sheath

7 Primary crossing with Viance catheter
Right lateral view

8 Viance blunt microdissection catheter
Torque Handle Distal Catheter Tip (rounded, atraumatic, 1 mm) (a) (b) 0.014” guidewire (300 cm) 135 cm shaft (2.3F) 0.035 OD: compatible with most support catheters

9 Subintimal passage and re-entry with Enteer
Successful TP trunk re-entry with Enteer catheter & wire Followed by IVUS confirmation

10 IVUS confirmation of distal true lumen access
Sub-intimal space s/p balloon dilation Compressed true lumen atheroma

11 Enteer re-entry catheter
Orienting balloon with radio-opaque markers indicating wire-exit ports on diametrically opposite sides of the balloon Stingray GW with ” distal taper

12 Final result after distal SFA & TP trunk stenting
6x40mm nSES Two 3x38mm DES Significant improvement in patient symptoms at 3m F/U

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