Bilateral leg runoff
HERE IS THE COPY OF THE 2 DAY PROCEDURE .. IT'S QUITE A BIT, THANK YOU FOR YOUR INTEREST.
DATE OF PROCEDURE: 12/30/2009
PREPROCEDURAL DIAGNOSIS: Intractable claudication with left superficial
femoral artery chronic total occlusion.
POSTPROCEDURAL DIAGNOSIS: Left superficial femoral artery chronic total
occlusion, status post stenting with subsequent thrombus embolization to the
distal vessels.
PROCEDURES PERFORMED:
1. Bilateral leg runoff.
2. Left superficial femoral artery angiogram.
3. Left superficial femoral artery angioplasty.
4. Left superficial femoral artery stenting.
5. Infusion catheter placed for TPA to the distal left leg vessels.
COMPLICATIONS: Emboli to the distal left leg vessels.
PROCEDURE DETAILS: Patient was prepped and draped in a sterile manner. A
4-French short sheath was placed into the right femoral artery. Pigtail was
placed into the aortoiliac junction. Angiogram demonstrated 100% occlusion of
the SFA at the ostium to the distal 1/3 with mild collaterals coming from the
left profunda. Subsequently a 4-French LIMA catheter was placed into the
ostium of the left iliac and a stiff-angled glidewire was advanced into the
profunda. The LIMA catheter was then advanced. The glidewire was then
exchanged out for a stiff Amplatz wire. The LIMA catheter was exchanged out,
and a 7-French Destination catheter was placed; was advanced across the horn
of the aortoiliac junction into the left iliac. Thereafter, the angled
glidewire and glide catheter were used to penetrate the chronic total
occlusion and were able to advance into the ongoing SFA and subsequently into
the popliteal.
Thereafter, a 5 x 100 peripheral balloon was advanced and ballooned 3 times
over the chronic total occlusion leaving multiple small dissections and a
significant amount of thrombus in the mid SFA. Thereafter, a 7 x 150 Cordis
Smart self-expanding stent was placed in the mid third of the SFA, covering
the thrombus. Thereafter, a 7 x 60 mm Smart Control Nitinol stent was placed
proximally to that. Thereafter, a 7 x 59 mm balloon expandable Palmaz Genesis
stent was placed from the ostium of the SFA into the proximal SFA. There were
residual 30% lesions that would have required post-stent dilatation; however,
subsequent angiogram after stenting demonstrated thrombus in the distal
vessels occluding the anterior tibialis, posterior tibialis and peroneal
vessel.
Thereafter, the LIMA catheter was placed back into the popliteal. An Amplatz
was advanced into the popliteal. The Destination catheter was exchanged out
for a short 7-French sheath. The LIMA catheter was then placed over the
Amplatz wire and the Amplatz wire was exchanged out for a long Confianza wire.
The LIMA catheter was then exchanged out for a Renegade infusion catheter
which was placed into the distal popliteal. The Confianza was then removed and
TPA was administered. During initial evaluation of the thrombus in the distal
vessels, Integrilin was hung. Patient subsequently noted improvement in his
left leg pain with TPA infusion. Patient will be admitted to the ICU for
overnight infusion of Retavase.
FINDINGS:
1. Chronic total occlusion of the SFA status post angioplasty and stenting .
2. Complication of distal embolization into the distal leg vessels involving
the anterior tibialis, posterior tibialis and the peroneal vessel.
3. Infusion catheter with Retavase for chemical thrombectomy along with
Integrilin and heparin infusions.
_________________________
, MD
Dictated by: MD
DATE OF SERVICE: 12/31/2009
PREPROCEDURE DIAGNOSES: Left distal vessel embolization and left superficial
femoral artery stenting.
POSTPROCEDURE DIAGNOSES: Distal vessel embolization with a residual mild clot
involving the mid posterior tibialis artery.
OPERATION/PROCEDURE: Superficial femoral artery angioplasty, left leg runoff
and a posterior tibialis angioplasty.
PROCEDURE PERFORMED BY: Dr. Aggarwal.
ANESTHESIA: IV Versed and fentanyl with local lidocaine.
COMPLICATIONS: None.
FINDINGS: The patient was prepped and draped in a sterile manner. The short
7-French sheath was exchanged out for a 7-French Destination using modified
Seldinger technique. Left leg runoff demonstrated patent SFA with residual
30% lesions in the prox and mid SFA and patent anterior tibialis and
superficial perioneal artery. The mid posterior tibialis was occluded but the
distal posterior tibialis was filled by collaterals from the other 2 vessels.
A Magic Torque wire was placed after a glidewire was exchanged out. A
6-French 100 mm balloon was used to inflate and post dilate the stents to a 0%
residual. Thereafter, a Confianza wire was placed into the posterior tibialis
and a 2.5 x 60 mm balloon was inflated over multiple times, using Integrelin
and heparin. There was improvement in the vessel; however, there was still
persistent clot despite extraction with a Quick-Cross and syringe suction.
There remained 100% mid posterior tibialis obstruction measuring approximately
10-15 mm in length. Nipride and nitroglycerin were injected through the
Quick-Cross into the mid posterior tibialis with no avail. However, the
patient was pain free and had distal constitution _____ collaterals.
Therefore, no further intervention was done. The patient will be placed on
Integrelin overnight.
FINDINGS: Patent saphenous vein graft stents with post-stent ballooning and
100% mid posterior tibialis with unsuccessful angioplasty.
,MD
