<![CDATA[ISEVS - Case Library]]>

<![CDATA[ISEVS - Case Library]]>Sun, 05 Apr 2026 05:09:20 -0500Weebly<![CDATA[Dialyzed patients with critical limb-threatening ischemia, no-option, or not?]]>Mon, 24 Feb 2020 08:00:00 GMThttps://www.isevs.org/case-library/dialyzed-patients-with-critical-limb-threatening-ischemia-no-option-or-not

Hsuan-Li Huang, MD
ISEVS Japan Chapter
Program Director

Director-Peripheral vascular center,
Division of Cardiology, Taipei Tzu-chi Hospital, New Taipei, Taiwan

Clinical History

This 74-year-old female patient has a history of type II diabetes mellitus, coronary artery disease, and end-stage renal disease undergoing regular dialysis. She presented with an unhealing ankle ulcer of the right foot for a couple of weeks (Figure 1). Endovascular therapy (EVT) was attempted, but in vain before the referral. Her ankle-brachial pressure index at the right leg is 0.72 (93 mmHg).

Figure 1

Procedure

Figure 2

The angiography is performed via the right antegrade approach, which revealed isolated below-the-knee disease with preserved anterior tibial, dorsalis pedis, and peroneal arteries but posterior tibial (PTA) and lateral plantar arteries (LPA) are occluded.

The intervention started with 4 F 45 cm shuttle tibial sheath (Cook) in 6 F Terumo sheath to increase support. We used a 0.014 Command (Abbott) guidewire supported by 0.018 CXI catheter (Cook) to cross the long-occluded PTA. The wire went smoothly down to the ankle due to prior intervention. However, the wire cannot advance into LPA. Rendezvous technique via pedal arch cannot gain success. During the wire manipulation, the PT2 guidewire went through another channel with low resistance. The tip injection of contrast medium showed the wire was located in the posterior tibial vein. We used the 2.5 mm Amphirion balloon catheter to create the arteriovenous (AV) channel between the lateral plantar vein (LPV) and LPA. The final result showed the rapid blood flow to the ankle site via this AV channel.

Conclusions/Results

Figure 3

After the EVT, the wound pain improved, and the duplex ultrasound revealed the remarkable increase of blood flow in the LPA and pulsatile waveform spectrum in LPV. The ankle pressure went up to 136 mmHg three days after the EVT, which was in line with increased ankle perfusion by radionuclide arteriography. This wound healed completely 2.5 months after the EVT.

In conclusion, planned or unplanned AV channel creation holds some promise to avoid major amputation in dialyzed patients with possible no-option critical limb-threatening ischemia.

]]><![CDATA[Bone marrow mononuclear cell implantation as an effective therapeutic option for the untreatable critical limb ischemia patient with endovascular therapy]]>Wed, 12 Feb 2020 15:52:29 GMThttps://www.isevs.org/case-library/bone-marrow-mononuclear-cells-implantation-as-an-effective-therapeutic-option-for-the-untreatable-critical-limb-ischemia-patient-with-endovascular-therapy

Kan Zen, MD
ISEVS Japan Chapter
Program Director

Department of Cardiovascular Medicine,
Kyoto Prefectural University of Medicine Hospital,
Kyoto, Japan.

Clinical History

This is a 58-year-old male with a long history of Buerger’s disease (18 years). He has stopped smoking completely when he has been diagnosed. He presented with rest pain in the left leg and non-healing ulcers on his left first and fifth toe. His left ankle brachial index (ABI) was measured at 0.79 and skin perfusion pressure (SPP) was 14 mmHg around wound. Anterior and posterior tibial and peroneal artery was occluded and the artery above the knee was patent. Two times of endovascular therapy failed and hyperbaric oxygen therapy was not effective in another hospital. Finally, he was admitted to our hospital for undergoing autologous bone marrow mononuclear cell (BM-MNCs) implantation therapy.

Procedure

Approximately 600ml of bone marrow was harvested from the bilateral iliac bones and mononuclear cells were separated with centrifuge. 3.48x109 of mononuclear cells were implanted using small needle injection into the muscle of the left lower limb and around the wound.

Conclusion

Rest pain was relieved from 6/10 to 4/10 by numerical rating scale one month after the BM-MNCs implantation. Three months after the BM-MNCs implantation, rest pain disappeared and visible healing of the first toe ulcer was observed. SPP also increased to 32 mmHg around wound. Six months after the BM-MNCs implantation, SPP increased to 42 mmHg around wound and the first toe ulcer was almost scabbing. Angiogenesis using BM-MNCs implantation might be one of options for no-option critical limb ischemia patients.

]]><![CDATA[Trans-collateral angioplasty in total occlusion from distal superficial femoral artery to infrapopliteal artery]]>Sun, 09 Feb 2020 08:00:00 GMThttps://www.isevs.org/case-library/trans-collateral-angioplasty-in-total-occlusion-from-distal-superficial-femoral-artery-to-infrapopliteal-artery

Su Hong Kim, MD
ISEVS Asia Chapter
Program Director
Yoshinori Tsubakimoto, MD
ISEVS Japan Chapter

Busan Veterans Hospital
Busan, South Korea

Kyoto Second Red Cross Hospital
Kyoto, Japan

Clinical History

This is a 90 year-old male, ex-smoker, with a history of heart failure, prior fem-pop bypass graft and dementia. He presented with a non-healing wound and tissue necrosis on his left first to third toe, and color change at the dorsum of left foot and distal lower leg (Figure 1). His left ankle-brachial index (ABI) was measured as 0.00, and he was classified as Rutherford Becker VI.

Figure 1

Procedure

Diagnostic angiography via right common femoral antegrade approach revealed total occlusion from distal superficial femoral artery(SFA) to left foot. Reconstituted island was noted at popliteal artery (zone 2) (Figure 2). No vessel runoff to the ankle was observed. Revascularization from SFA to the below the ankle artery was planned with as many as possible manner. Ipsilateral antegrade access was obtained with a 6Fr Ansel sheath. The femoropopliteal occlusion was crossed with a corsair microcatheter over a 0.014 inch Gladius guide wire. After successful crossing to the peroneal artery, balloon angioplasty with done from peroneal artery to distal SFA. Then I could see the flow from peroneal artery to the posterior tibial artery(PTA) via collateral channel. Subsequently, a 0.014 inch Regalia guide wire was advanced to the PTA with corsair microcatheter via collateral channel(Figure 3). After advancing the retrograde wire to the proximal PTA, I advanced a 0.014 inch Astato-XS (tip load : 20g) guide wire to the PTA and then wire randez-vous was done successfully. After balloon angioplasty at the PTA, I could see the blood flow to toes.

Figure 2

Figure 3

Conclusion

7 days following the procedure, He was suffered with aggravating dyspnea due to heart failure and transfer to the intensive care unit. After recovery of the aggravated heart failure, below the ankle level amputation was done at 15 days post-procedure. Although very old aged patient with wound, it is important to reduce the level of amputation after successful revascularization.

]]><![CDATA[Right Internal Carotid Artery Stenting]]>Wed, 17 Jul 2019 05:00:00 GMThttps://www.isevs.org/case-library/right-internal-carotid-artery-stentingOperators: Jan Skowronski, MD; Gary Roubin, MD; Brad Cavender, MD

Clinical Vignette
67 yo AFAB
Debilitating B/L LEs claudication
Comorbidities HTN, dyslipidemia, h/o tobacco use
Exam: absent femoral pulses, R. Neck bruit
Ultrasound:
RICA: 370/106
R. Innominate artery: 320/80
R. Subclavian artery: moderate stenosis

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