Encounter-Level Hemodynamic Waveforms:
After obtaining informed consent, the patient was prepped and draped in the usual fashion. Approximately 10 mils 2% lidocaine anesthesia was administered to the right groin prior to placement of the arterial sheath. Under fluoroscopic guidance and using modified Seldinger technique, a 5 French arterial sheath was placed to the right femoral artery. We then obtained a 5 French contra catheter which was positioned in the distal abdominal aorta above the bifurcation. We performed nonselective digital subtraction angiography of the aorta with bilateral iliofemoral runoff. This revealed patent bilateral common, external, and internal iliac vessels to the level of the common femoral vessels bilaterally. Then, with assistance from 0.035 inch stiff angled tip ZIP wire, we attempted to advance the contra catheter into the distal external iliac on the left. Unfortunately, because of tortuosity, this was not possible. We therefore exchanged this for a 5 French rim catheter which was extended and advanced successfully into the distal common femoral vessel. We then performed selective digital subtraction angiography of the right lower extremity. This revealed a common femoral vessel which was widely patent. The SFA and profunda were patent as well. The profunda was free of disease. The SFA had a lengthy area of proximal 70 to 75% disease followed by an area of relative normalization and another lengthy area of 70 to 80% disease terminating at the adductor canal. The popliteal vessel was patent throughout its proximal, middle, and distal segments. The anterior tibial vessel was occluded proximally. The tibioperoneal trunk was patent but had a 50% stenosis prior to the bifurcation. The posterior tibial vessel was diffusely diseased and occluded in the midsegment. The peroneal vessel was patent throughout its entire course, and there was distal reconstitution of the posterior tibial vessel and partially of the anterior tibial vessel.
After confirmation of these findings, we elected to proceed with peripheral intervention. The 5 French rim catheter and 5 French contra were removed over a long Magic torque wire and exchanged for a 7 x 45 cm destination sheath. Heparin at a dose of 2500 units per intravenous bolus was administered to achieve an activated clotting time appropriate for the procedure. Later, due to sluggish vascular filling of the foot vessels, Aggrastat by intravenous bolus and infusion was added. We then obtained a 300 cm length 0.014 inch Thruway wire which was advanced without difficulty into the proximal peroneal vessel. We then proceeded with jetstream atherectomy of the SFA utilizing a 2.4/3.4 mm bur. Follow-up angiography after atherectomy revealed improvement in the overall caliber of the vessel with areas of linear dissection in the mid and distal SFA. There was TIMI grade III flow into the popliteal vessel. There was no change in filling parameters in the anterior tibial vessel, though the posterior tibial vessel was now occluded more proximally. There was sluggish flow into the peroneal vessel. On further runoff angiography, there was evidence of loss of flow in the very distal peroneal vessel with loss of collaterals and diminished perfusion in the foot. Despite this, the patient curiously had no foot pain. Concerned about these results, we started Aggrastat and gave intra-arterial nitroglycerin with minimal improvement in flow dynamics. We then decided to further advance the throughway wire. Initially the flu a wire was advanced into the distal posterior tibial vessel which re-created a channel and allowed for perfusion of the foot through the posterior tibial vessel. We then withdrew the wire and advanced it into the distal peroneal vessel beyond the point of occlusion and into 1 of the collaterals. We then performed balloon angioplasty of the area of occlusion utilizing 1.5 x 20 mm emerge push balloon deployed to 12 atm of pressure over 2 overlapping inflations. Follow-up angiography after balloon dilatation revealed resumption of antegrade flow into the peroneal vessel with slow but improved perfusion into the foot. Satisfied with this result for the moment, we turned our attention back to the SFA. We performed a drug-eluting stenting of the SFA utilizing, from distal to proximal, a 6.0 x 120, 6.0 x 120, and 6.0 x 80 mm Eluvia including stents. Entire stented length was then postdilated utilizing a 5.0 x 220 mm Sterling balloon up to a size 14 atm of pressure. Follow-up angiography revealed an excellent result within the stented segment with brisk TIMI grade III flow throughout the SFA and popliteal vessel. The appearance of the tibioperoneal trunk was unchanged. The anterior tibial vessel remained occluded. The posterior tibial vessel remained subtotally occluded with improved filling into the foot the peroneal vessel was patent with sluggish but improving flow into the foot as well. Satisfied with the result, we elected to conclude the procedure. The guidewire was removed and final angiography revealed no change in the appearance of the vessel.
We then withdrew the destination sheath to the level of the external iliac on the right and performed nonselective injection of the right iliofemoral system. This revealed occlusion of the previously placed femoropopliteal bypass graft proximally with a widely patent common femoral vessel and subtotal occlusion in the SFA. As the vessel was large enough to allow for closure device, and after confirmation of an activated clotting time of 192 seconds, the 7 French long sheath was exchanged for short 7 French sheath, after which a minx was deployed for hemostasis.
The patient was then transferred to the recovery area in stable condition.
1. Severe diffuse disease of left SFA status post successful atherectomy and drug-eluting stent placement.
2. Moderate tibioperoneal trunk disease on the left.
3. Chronic occlusion of posterior tibial anterior tibial vessel.
4. Thrombotic occlusion of distal peroneal vessel status post successful recanalization and balloon angioplasty.
5. Occluded right femoral-popliteal bypass graft
6. Status post minx placement.
thank you in advance
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Encounter-Level Hemodynamic Waveforms: