Conclusion

After obtaining informed consent, the patient was prepped and draped in the usual fashion. Approximately 5 mL's of 2% lidocaine anesthesia was administered just above the left antecubital fossa. Utilizing a micropuncture kit. A 6 French sheath was placed in the left brachial artery. We then instilled 3000 units of heparin within the sheath to prevent thrombosis. Following this, we obtained a C2 Cope catheter which was advanced over a standard procedural J-wire into the distal abdominal aorta. We then exchanged this wire for 260 cm length Magic torque wire. The Cope catheter was then removed, as was the short arterial sheath, and replaced by a 6 x 90 cm destination sheath. We then advanced the destination sheath over the Magic torque wire into the right limb of the aortobiiliac graft. We performed digital subtraction angiography of this graft which revealed patency of the graft but a focal severe 90% plus stenosis at the graft anastomosis into the external iliac vessel. Beyond this, the common femoral vessel was patent as were the profunda femoris artery and the recently placed right femoral-popliteal graft. The right SFA was occluded. With assistance from a 4 French angled tip 120 cm glide catheter, we advanced the Magic torque wire into the profunda femoris artery. 4000 units of intravenous heparin was administered in order to achieve an activated clotting time appropriate for the procedure. As the patient was already on dual antiplatelet therapy, no additional loading doses were administered. We performed predilatation of the stenosis at the graft anastomosis first utilizing a 6.0 x 40 mm Mustang balloon deployed up to 14 atm of pressure. Follow-up angiography after balloon angioplasty revealed an improvement in the appearance of the vessel, though this balloon was undersized relative to the graft and the vessel itself. We then performed additional predilatation utilizing a 7.0 x 80 mm Mustang balloon again up to 14 atm of pressure. Follow-up angiography revealed a further improvement in the appearance of the vessel. We then elected to proceed with stenting. We obtained an 8 x 60 mm epic vascular self-expanding nitinol stent which was deployed extending from the graft into the distal external iliac vessel. Follow-up angiography revealed a good angiographic result with some residual stenosis at the site of the original lesion. We then performed postdilatation of this region utilizing an 8.0 x 40 mm Mustang balloon up to 14 atm of pressure. Follow-up angiography revealed a very good angiographic result with no significant residual stenosis and no evidence of proximal or distal stent edge dissection, thrombosis, or spasm. There was TIMI grade III flow throughout, and the patient was asymptomatic. We then concluded this portion of the procedure.
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We then performed a digital traction runoff angiography of the right lower extremity. This again revealed a widely patent common and profunda femoris artery with an occluded SFA. The right femoral-popliteal graft was widely patent throughout its proximal, middle, and distal segments, and filled the popliteal artery across the knee. There was three-vessel runoff below the knee with mild nonobstructive disease in the runoff vessels. Satisfied with this result, we then withdrew the destination sheath to the level of the proximal graft and perform digital subtraction angiography of the aortoiliac vessels. This again revealed a widely patent stent extending into the external iliac on the right. On the left, the aortoiliac graft was patent, but there was yet another area of focal stenosis at the graft insertion of 80-90% severity. The external iliac beyond as well as the common femoral were patent. Due to continued complaints of claudication on the patient's heart on the left, we elected to intervene in this vessel as well. We readvanced the Magic torque wire and, with assistance from the aforementioned glide catheter, advanced across the stenosis. We then performed predilatation of the stenosis utilizing first a 6.0 x 40 mm Mustang balloon, followed by 7.0 x 40 mm Mustang balloon up to 14 atm of pressure. Follow-up angiography revealed improvement in the appearance of the vessel, and we proceeded with stenting, placing an 8.0 x 40 mm epic self-expanding nitinol stent in this region. We then performed postdilatation utilizing the aforementioned 8.0 x 40 mm Mustang balloon up to 14 atm of pressure. Follow-up angiography revealed an excellent result with no significant residual stenosis and TIMI grade III flow beyond. We then concluded this portion of the procedure. The Magic torque wire was withdrawn, and final angiography of the iliofemoral system revealed no change in the appearance of the vessel.
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At the end of the procedure, and ending activated clotting time was 157 seconds, so the 6 French destination sheath was withdrawn and manual compression was utilized for hemostasis. The patient was then transferred to the recovery area in stable condition.
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Impression:
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1. Severe bilateral lower extremity claudication, status post successful angioplasty and self-expanding stenting of bilateral aortoiliac anastomoses.
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Plan:
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1. Aspirin for life.
2. Plavix indefinitely.
3. Aggressive risk factor modification.
Contrast

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