Case presentation: Critical Limb Ischemia

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Presentation transcript:

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

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

Diagnostic angiographic images

Diagnostic angiographic images

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

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

Primary crossing with Viance catheter Right lateral view

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

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

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

Enteer re-entry catheter Orienting balloon with radio-opaque markers indicating wire-exit ports on diametrically opposite sides of the balloon Stingray GW with 0.0035” distal taper

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