Endovascular repair of right popliteal artery aneurysm with Viabahn covered stents

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Procedure list in detail:
1. Repeat right lower extremity arteriogram
2. Discontinuation of thrombolytic therapy with catheter removal
3. Percutaneous atherectomy with Hawk 1 device of the peroneal artery
4. Balloon angioplasty of the peroneal artery
5. Endovascular repair of right popliteal artery aneurysm with Viabahn covered stents
6. Aspiration embolectomy of the peroneal artery with Pronto catheter

Indications: Thrombosed popliteal artery aneurysm with thromboembolism and critical ischemia of the right lower extremity

Description of the procedure:
Patient was placed in supine position. Procedure began initially with moderate sedation and eventually converted to LMA general. The patient's left femoral sheath was prepped and draped in the EKOS ultrasound wire removed from the EKOS catheter. Angiogram was performed to the EKOS catheter. Endovascular interventions were then performed as described below. Following endovascular interventions sheath was removed and Pro-glide closure performed of the femoral sheath site.

Angiographic findings in detail and endovascular interventions:
Initial arteriogram shows that the patient has a partially thrombosed popliteal artery aneurysm with significant residual thrombus burden and stenotic flow. There is patency of the below-knee popliteal artery. There is single-vessel peroneal runoff which is obstructed proximally. Anterior tibial artery is chronically occluded. The posterior tibial artery is severely chronically diseased and functionally occluded.

I 1 4 wire was positioned in the peroneal artery and initial balloon angioplasty was performed with 3 mm and then 4 mm balloons. There was residual narrowing in the proximal peroneal artery. Was not clear whether this was thrombus or eccentric plaque. The Medtronic Hawk 1 atherectomy device for 2 to 4 mm vessels was then used to atherectomized this lesion. This was followed by 3 and 4 mm balloon angioplasty. Eventually we had acceptable result with no significant residual stenosis in the peroneal artery.

We then exchanged an 018 wire system and began stent angioplasty of the popliteal artery aneurysm. 7 mm x 15 cm Viabahn and and stents were placed from the distal popliteal into the proximal popliteal artery. Additional injection showed that due to residual narrowing and thrombus within the SFA a third 7 mm x 5 cm Viabahn stent was placed proximally. All of the stents overlapped. All the stents were postdilated with a 7 mm balloon. Follow-up arteriogram showed good flow through the stented popliteal artery aneurysm but there was no obstruction in the peroneal artery again. Most likely from embolus.

Wire was maintained across the obstruction during the entire time. A series of maneuvers were then performed including aspiration with a Pronto embolectomy catheter which was only partially successful. Multiple balloon inflations with 3 and 4 mm balloons were then used to attempt to efface the thrombus and some inflations use the PTA balloon as a embolectomy balloon. Eventually I was able to clear the peroneal artery with what appeared to be a very distal embolic occlusion down into the collateralized plantar branch of the peroneal artery. Unfortunately due to the patient's height I did not have a angioplasty balloon that would reach into the plantar vessels. Outflow of the peroneal artery however was maintained by the collateralized PT and its side branches.

The patient's 7 French sheath was subsequently removed and Pro-glide closure performed of the femoral sheath site with good hemostasis. The patient had moderate hematoma in the left groin which appeared to be cumulative during the case as well as some pre-existing beginning the case. Following the Pro-glide closure this appeared to be stable.

Summary of findings:
1. Thrombosed popliteal artery aneurysm successfully treated with covered stent angioplasty
2. Peroneal artery stenoses and emboli successfully treated with balloon angioplasty, atherectomy and aspiration embolectomy
3. Distal collateralized posterior tibial and plantar artery branch occlusion likely from emboli
 
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