AORTOFEMORAL ARTERIOGRAM, LEFT LEG RUNOFF, LEFT LEG ATHERECTOMY AND
ANGIOPLASTY AND STENT AS WELL AS ANGIOPLASTY - 08/23/2010
INDICATION: Ulcer, left foot.
The patient was identified on the operating room table. The groins were prepped and draped in the usual sterile fashion. I accessed the right femoral artery utilizing a mini stick kit and a #5 French sheath. The patient has a slightly elevated BUN and creatinine so I was just really focusing on the left leg. He had no open areas on his right leg. The Omni flush catheter was positioned at the distal aorta. Aortofemoral arteriogram was performed. That revealed no significant distal aortic stenosis. The iliac arteries were patent without significant stenosis though there was disease. The right internal iliac artery was occluded. The right common femoral artery had disease within it and maybe a mild to moderate stenosis within it. The profunda and proximal superficial femoral arteries were patent but this had significant calcification within it.
On the left the common femoral artery was patent. The profunda femoral artery patent. There was a femoral popliteal graft which was patent though somewhat tortuous. The distal graft was patent to the popliteal artery. There was not a significant stenosis in that area. The patient had a prosthesis of the left knee. We did angle views and there was some disease behind that knee but it did not appear to be hemodynamically significant. The tibioperoneal trunk was occluded. The peroneal artery seemed to the dominant flow to the left leg and that was occluded. The anterior tibial occludes in the proximal leg and the posterior tibial occludes in the mid leg. I was able to get a wire into peroneal artery and then after this was done I proceeded to give the patient 6,000 units of heparin. I atherectomized the tibioperoneal trunk occlusion as well as the proximal peroneal artery occlusion. After this was completed, I angioplastied with a 2.5 scored balloon angioplasty. That improved the flow in the peroneal and in the tibioperoneal trunk area. I decided to place a 4 x 18 balloon mounted stent across that tibioperoneal trunk area for better flow. Once that was done that helped to again improve the inflow there. In the mid peroneal artery there was a focal stenosis which I tried to get across with multiple balloons to see if I could just maximize the flow into that left leg. I was unable to do that. I could not get the atherectomy device across it. I could not get a 2 x 20 balloon across it and tried multiple different techniques to try to get across this and I was unsuccessful. At this point I stopped. I had improved the inflow and I felt that by doing that I hopefully helped this flow to his left leg. I did not have any different options to get across that peroneal artery stenosis. It was a focal stenosis. The artery though was very small and calcified and because of this I really just could not get enough push to get across that lesion. Therefore, I stopped at this point. I removed the wires and sheath. I used an Angio-Seal device on the right groin. When I was imaging through the left leg, I did image the left leg with a catheter in the left femoral-popliteal graft and then I exchanged out for a #6 French sheath which was positioned in the left femoral popliteal graft. I went over the top from the right side to the left side with the Omni flush catheter.
IMPRESSION: SIGNIFICANT CALCIFICATION OF HIS VESSELS BILATERALLY. HIS PRIMARY PROBLEM IS RUNOFF DISEASE OF HIS LEFT LOWER EXTREMITY. I WAS ABLE TO ADDRESS SOME OF THE PROXIMAL LESIONS OF THE LEFT TIBIOPERONEAL TRUNK AND PROXIMAL PERONEAL ARTERY, HOWEVER, SOME OF THE MORE DISTAL LESIONS I WAS NOT ABLE TO ADDRESS.
Any advice is appreciated.
Thanks
