Trans-collateral angioplasty in total occlusion from distal superficial femoral artery to infrapopliteal artery

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

Busan Veterans Hospital
Busan, South Korea
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Kyoto Second Red Cross Hospital
​Kyoto, Japan

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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

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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

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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.