Please help !!

PROCEDURE:
1. Right common femoral artery angiography with runoff.
2. EKOS catheter removal.
3. Intraarterial thrombolysis.
4. Atherectomy, ostial right proximal anastomosis of Cryovein
fem-pop bypass.
5. Cutting balloon atherectomy distal anastomosis of right
fem-pop bypass to tibioperoneal trunk.
6. Percutaneous transluminal angioplasty of right posterior
tibial artery.
7. Possis AngioJet for post intra-arterial thrombolysis with
TPA.
8. Possis AngioJet thrombolysis of right fem-pop bypass graft.

COMPLICATIONS:
None.

INDICATIONS:
Graft occlusion, graft failure, thrombosis of right fem-pop
bypass graft, angiography to assess right fem-pop bypass, post
lysis and EKOS catheter placement.

DESCRIPTION OF PROCEDURE:
This 68-year-old male returns to the endovascular lab for stage
II intervention. The patient is 20 hours post-EKOS catheter
placement, right fem-pop bypass graft, which is noted to be
chronically occluded. The patient is taken to the cath lab on
intravenous heparin and TPA infusion 0.5 mg per hour via EKOS
catheter noted, a 6-French contralateral sheath flexor 45 cm in
place via left groin. The patient is prepped and draped. The
EKOS catheter was removed and angiography was performed via the
flexor sheath with placement of a 100 cm Glidewire. This
demonstrates faint flow through the vein graft to the fem-pop
bypass graft down to the legs. However, significant thrombotic
residue still noted. Placement of a glide catheter down
distally, does demonstrate indeed that the runoff is adequate
from the fem-pop graft to the tibioperoneal trunk with runoff to
a single-vessel posterior tibial artery on the right; however, a
stenosis of the ostium of the right posterior tibial artery is
noted of at least 95%, and this is dilated, utilizing a BMW 300
cm guidewire of 0.014 inch with 2 mm x 10 mm Trek balloon, which
was subsequently exchanged for a flex time cutting balloon
Monorail 2 mm x10 mm, which is utilized for sequential dilations
6, 8 and 10 atmospheres, 30 seconds x3 at the distal anastomosis.
The AngioSculpt PTA scoring balloon catheter 4 mm x 20 mm was
also utilized for the distal anastomosis, which does restore
runoff down to the PTA on the right. This is performed at 8
atmospheres, 10, 12 atmospheres, 20 seconds x 3. The proximal
anastomosis of this fem-pop bypass is performed with a 6 mm x 20
mm AngioSculpt PTA balloon at 6, 8, 12 atmospheres, 20 seconds
each, which does restore grade I flow down the leg. An AngioJet
Ultra Omni catheter 100 cm is then passed down the right leg over
the 0.014 inch guidewire for post thrombolysis with TPA;
additional 2 mg injected and kept in place for 15 minutes.
Subsequently, thrombolysis with clot retrieval is performed with
the same catheter. The final angiograms were then performed.
This demonstrates now patent ostium of this bypass, which is a
patulous vein graft patch without residual thrombus. The mid
vein graft is now noted to have mild luminal irregularity, but
flow has returned to normal down to the tibioperoneal trunk
entrance with runoff to the posterior tibial artery still noted,
however, with significant small vessel disease beyond but much
improved flow. No residual stenoses that warrant further
intervention required. Over an 0.035 inch guidewire, the
6 French catheter flexor Sheath 45 cm is exchanged for a
6-French sheath, 10 cm Cordis placed in the left common femoral artery
and sutured in place. The patient was heparinized throughout the procedure and
maintained an ACT greater than 250 seconds. The heparin infusion
was discontinued. The patient will continue on long-term aspirin
and Plavix. Sheath removal over the next 4 hours as planned. The
patient will return to the ICU for further care.

FINAL IMPRESSION:
Successful revascularization of acute on chronic occlusion
recurrence of patched fem-pop bypass of the right leg with
restored pedal pulses post intervention.