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