em2177
Expert
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REASON FOR EVALUATION: Claudication.
HISTORY OF PRESENT ILLNESS: The patient is well known to me from a recent
coronary angiography with bypass grafting from the right common femoral artery.
The patient tolerated that procedure well. However, later the patient began
to have increasing right leg pain, which was typical for claudication. The
patient then came to see me. He did have positive pulses. However, due to the
concern of right leg pain, an ultrasound was performed showing an occlusion of
the right common femoral artery. The patient did have his original
catheterization on February 23, 2012, where an Angio-Seal was placed. Due to
the significant lesion at the right common femoral artery, the patient has been
explained the risks, benefits, and alternatives of peripheral angiography
plus/minus angioplasty and stenting. The patient agrees to proceed.
PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion. Lidocaine was placed to the left common femoral
area. Using micropuncture technique, a 6-French sheath was placed in the left common
femoral artery. Next up-and-over access was obtained with a LIMA catheter
using a Glidewire. The LIMA catheter was placed into the right, and common
iliac angiography down the right side to the level of the proximal SFA was
performed. This showed a proximal right external iliac occlusion just after
the bifurcation of the internal iliac. The internal iliac provided good
collateral flow to the level of the common femoral artery and the bifurcation
of the SFA and the profunda.
At this point, a wire was placed to the right side. The LIMA catheter was
removed. A 6-French short sheath was exchanged for a 6-French Ansel sheath,
which was placed to the right common iliac. At this point, a Glidewire was
used to attempt to cross the lesion and appeared to be placed into the common
femoral artery. A balloon was brought down. The wire was removed. There was
retrograde blood flow into the balloon. However, angiography revealed a
dissection plane at this point. The wire was left in place. There was still
no change in flow into the proximal SFA. At this point, the wire was left in
place, and we used a Luge wire to attempt to recross not entering the
dissection plane. We entered into the level again of the common femoral
artery. However, repeat angiography showed a concern of staying in the
dissection plane. We tried a S'Port wire. This was also not successful. Thus
we removed all wires and the balloon. Repeat angiography showed no change in
caliber of flow through the internal iliac with reconstitution into the
bifurcation of the SFA and profunda.
Thus a catheter was brought back over to the left external iliac, and
angiography down the left leg was performed showing catheter sheath insertion
into the left common femoral artery and manual pressure was held after ACT was
stabilized. The patient tolerated the procedure well and remained
hemodynamically stable. There was good groin hemostasis with no evidence of
oozing, bruising, or hematoma.
IMPRESSION:
1. The bilateral common iliacs are widely patent.
2. On the right side, there is an occlusion of the right external iliac in the
proximal segment. There is a large internal iliac, which allows for
reconstitution at the level of the right common femoral artery just at the
takeoff of the profunda and the SFA. Otherwise, the proximal SFA is widely
patent. We were unable to cross into this segment.
3. The left external iliac, common femoral artery, and SFA are widely patent
with brisk flow in the infrapopliteal segments. No obvious significant
stenosis.
REASON FOR EVALUATION: Claudication.
HISTORY OF PRESENT ILLNESS: The patient is well known to me from a recent
coronary angiography with bypass grafting from the right common femoral artery.
The patient tolerated that procedure well. However, later the patient began
to have increasing right leg pain, which was typical for claudication. The
patient then came to see me. He did have positive pulses. However, due to the
concern of right leg pain, an ultrasound was performed showing an occlusion of
the right common femoral artery. The patient did have his original
catheterization on February 23, 2012, where an Angio-Seal was placed. Due to
the significant lesion at the right common femoral artery, the patient has been
explained the risks, benefits, and alternatives of peripheral angiography
plus/minus angioplasty and stenting. The patient agrees to proceed.
PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion. Lidocaine was placed to the left common femoral
area. Using micropuncture technique, a 6-French sheath was placed in the left common
femoral artery. Next up-and-over access was obtained with a LIMA catheter
using a Glidewire. The LIMA catheter was placed into the right, and common
iliac angiography down the right side to the level of the proximal SFA was
performed. This showed a proximal right external iliac occlusion just after
the bifurcation of the internal iliac. The internal iliac provided good
collateral flow to the level of the common femoral artery and the bifurcation
of the SFA and the profunda.
At this point, a wire was placed to the right side. The LIMA catheter was
removed. A 6-French short sheath was exchanged for a 6-French Ansel sheath,
which was placed to the right common iliac. At this point, a Glidewire was
used to attempt to cross the lesion and appeared to be placed into the common
femoral artery. A balloon was brought down. The wire was removed. There was
retrograde blood flow into the balloon. However, angiography revealed a
dissection plane at this point. The wire was left in place. There was still
no change in flow into the proximal SFA. At this point, the wire was left in
place, and we used a Luge wire to attempt to recross not entering the
dissection plane. We entered into the level again of the common femoral
artery. However, repeat angiography showed a concern of staying in the
dissection plane. We tried a S'Port wire. This was also not successful. Thus
we removed all wires and the balloon. Repeat angiography showed no change in
caliber of flow through the internal iliac with reconstitution into the
bifurcation of the SFA and profunda.
Thus a catheter was brought back over to the left external iliac, and
angiography down the left leg was performed showing catheter sheath insertion
into the left common femoral artery and manual pressure was held after ACT was
stabilized. The patient tolerated the procedure well and remained
hemodynamically stable. There was good groin hemostasis with no evidence of
oozing, bruising, or hematoma.
IMPRESSION:
1. The bilateral common iliacs are widely patent.
2. On the right side, there is an occlusion of the right external iliac in the
proximal segment. There is a large internal iliac, which allows for
reconstitution at the level of the right common femoral artery just at the
takeoff of the profunda and the SFA. Otherwise, the proximal SFA is widely
patent. We were unable to cross into this segment.
3. The left external iliac, common femoral artery, and SFA are widely patent
with brisk flow in the infrapopliteal segments. No obvious significant
stenosis.