em2177
Expert
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REASON FOR EVALUATION: Peripheral arterial disease.
HISTORY OF THE PRESENT ILLNESS: This patient is known to have significant
peripheral arterial disease status post bilateral stenting in the remote past.
The patient now has complained of progressive intermittent claudication, right
greater than left. He had a markedly abnormal ultrasound and thus, since it is
impending on his activities of daily living as well as his cardiac rehab, we
have explained the complete risks, benefits, and alternatives of peripheral
angiography, plus/minus angioplasty and stenting, and the patient agrees to
proceed.
The patient was brought to the catheterization laboratory and prepped and
draped in a sterile fashion. Lidocaine was placed to the left common femoral
area. Then a 6-French sheath was used with micropuncture technique to be
placed to the left common femoral artery. Angiography of the common femoral
arterial site and then followed down the left leg for evaluation of stenosis
was performed to the level of the ankle through the sheath. Next, through the
6-French sheath, a 6-French LIMA catheter was placed to the bifurcation of the
iliac. A Glidewire was placed into the right common femoral artery, and the
LIMA catheter was placed to the level of the right common femoral artery.
Glidewire was removed. Angiography down the right leg was then performed.
At this point the Glidewire was replaced, and LIMA catheter was removed. A
6-French short sheath was exchanged for a 6-French Ansel sheath. The Glidewire
was placed into the popliteal space under fluoroscopic guidance. Then serial
dilatation was performed with a 6.0 x 80 Fox Plus balloon. This was inflated
to 14 atmospheres over the entire segment of the SFA which has previously been
stented.
Balloon was removed. Wire was left in place. Repeat angiography down the
right leg was performed. There was 1 segment in the mid segment which
continued to have a greater than 30% residual stenosis. Thus, the balloon was
replaced, and repeat dilatation to 14 atmospheres was performed.
At this point balloon was removed, and repeat angiography down the right leg
was performed. Wire was removed. The Ansel sheath was brought back to the
left external iliac under fluoroscopic guidance. ACT after 3000 heparin at the
beginning of the procedure was performed, and manual pressure was held to the
left common femoral artery with good groin hemostasis and no evidence of
oozing, bruising, or hematoma.
IMPRESSION:
1. Bilateral iliacs and external common femoral arteries appear to be widely
patent.
2. On the right side the right SFA in its proximal segment all the way to the
popliteal space had previous stenting. Most of the segment appeared to be
fairly stable. However, there are multiple segments of severe in-stent
restenosis, 80-95% in a degree of stenosis. Status post balloon angioplasty
with a 6-0 balloon over the entire segment now reveals less than 10%
residual stenosis and overall significantly improved flow. The popliteal is
patent. There is a previous popliteal to posterior tibial graft which
appears to be patent. The anterior tibial is occluded. The posterior
tibial post angioplasty of the SFA now is widely patent and has multiple
collateral flows to the peroneal and anterior tibial and extends all the way
into the foot with good flow. The peroneal has faint flow post procedure.
3. The left SFA has mid-to-distal stents which appear to be stable. In the
proximal segment there is moderate-to-severe 70-80% focal type lesion. Then
distally, just at the distal edge and extending farther down the SFA
appears to be an 80-90% lesion. The popliteal artery is widely patent. The
posterior tibial is widely patent, and we are not able to visualize the
anterior tibial. The peroneal has a collateral flow distally.
REASON FOR EVALUATION: Peripheral arterial disease.
HISTORY OF THE PRESENT ILLNESS: This patient is known to have significant
peripheral arterial disease status post bilateral stenting in the remote past.
The patient now has complained of progressive intermittent claudication, right
greater than left. He had a markedly abnormal ultrasound and thus, since it is
impending on his activities of daily living as well as his cardiac rehab, we
have explained the complete risks, benefits, and alternatives of peripheral
angiography, plus/minus angioplasty and stenting, and the patient agrees to
proceed.
The patient was brought to the catheterization laboratory and prepped and
draped in a sterile fashion. Lidocaine was placed to the left common femoral
area. Then a 6-French sheath was used with micropuncture technique to be
placed to the left common femoral artery. Angiography of the common femoral
arterial site and then followed down the left leg for evaluation of stenosis
was performed to the level of the ankle through the sheath. Next, through the
6-French sheath, a 6-French LIMA catheter was placed to the bifurcation of the
iliac. A Glidewire was placed into the right common femoral artery, and the
LIMA catheter was placed to the level of the right common femoral artery.
Glidewire was removed. Angiography down the right leg was then performed.
At this point the Glidewire was replaced, and LIMA catheter was removed. A
6-French short sheath was exchanged for a 6-French Ansel sheath. The Glidewire
was placed into the popliteal space under fluoroscopic guidance. Then serial
dilatation was performed with a 6.0 x 80 Fox Plus balloon. This was inflated
to 14 atmospheres over the entire segment of the SFA which has previously been
stented.
Balloon was removed. Wire was left in place. Repeat angiography down the
right leg was performed. There was 1 segment in the mid segment which
continued to have a greater than 30% residual stenosis. Thus, the balloon was
replaced, and repeat dilatation to 14 atmospheres was performed.
At this point balloon was removed, and repeat angiography down the right leg
was performed. Wire was removed. The Ansel sheath was brought back to the
left external iliac under fluoroscopic guidance. ACT after 3000 heparin at the
beginning of the procedure was performed, and manual pressure was held to the
left common femoral artery with good groin hemostasis and no evidence of
oozing, bruising, or hematoma.
IMPRESSION:
1. Bilateral iliacs and external common femoral arteries appear to be widely
patent.
2. On the right side the right SFA in its proximal segment all the way to the
popliteal space had previous stenting. Most of the segment appeared to be
fairly stable. However, there are multiple segments of severe in-stent
restenosis, 80-95% in a degree of stenosis. Status post balloon angioplasty
with a 6-0 balloon over the entire segment now reveals less than 10%
residual stenosis and overall significantly improved flow. The popliteal is
patent. There is a previous popliteal to posterior tibial graft which
appears to be patent. The anterior tibial is occluded. The posterior
tibial post angioplasty of the SFA now is widely patent and has multiple
collateral flows to the peroneal and anterior tibial and extends all the way
into the foot with good flow. The peroneal has faint flow post procedure.
3. The left SFA has mid-to-distal stents which appear to be stable. In the
proximal segment there is moderate-to-severe 70-80% focal type lesion. Then
distally, just at the distal edge and extending farther down the SFA
appears to be an 80-90% lesion. The popliteal artery is widely patent. The
posterior tibial is widely patent, and we are not able to visualize the
anterior tibial. The peroneal has a collateral flow distally.
