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93 Percutaneous Intervention forInfrainguinal Arterial Occlusive Disease withHeel Ulcer
a stent placement after retrograde wire has been
snared and brought through the antegrade guide
catheter [3].
This case illustrates the necessity of repeat
interventions in patients with infrainguinal arterial occlusive disease. Since most patients with
foot ulcers have associated diabetes mellitus, a
multidisciplinary team approach consisting of
vascular surgeon, diabetologist, infectious disease specialist, and orthopedic foot and ankle
specialist is essential in achieving better outcomes. Unfortunately some patients will end up
with major amputation in spite of all efforts at
limb salvage.
References
1. Mohammad F, Nypaver TJ. Percutaneous interventions for femoral popliteal artery occlusive disease. In:
Hans SS, Shephard AD, Weaver MR, Bove PG, Long
GW, editors. Endovascular and open vascular reconstruction: a practical approach. Boca Raton: CRC
Press; 2018. p.35–41.
2. Strot SEB, Cuff R. Percutaneous interventions
for infrapopliteal occlusive disease. In: Hans SS,
Shephard AD, Weaver MR, Bove PG, Long GW, editors. Endovascular and open vascular reconstruction:
a practical approach. Boca Raton: CRC Press; 2018.
p.43–8.
3. Bazan HA, Le L, Donovan M, Sidhom T.Retrograde
pedal access for patients with critical limb ischemia. J
Vasc Surg. 2014;60(2):375–82.
Angioplasty forFemoral-Tibial
inSitu Vein Bypass Stenosis
94
Patient A: History andProcedure
An 88-year-old female was referred by her podiatrist after undergoing second toe amputation for
ischemic gangrene. Medical comorbidities
included hypertension and hyperlipidemia. Ankle
brachial index (ABI) on the right side was 0.6
and 0.8 on the left. She underwent right popliteal
(above the knee) angioplasty and stent placement
for popliteal artery occlusion in June 2018.
However patient developed stent thrombosis 2
months later was treated with thrombolysis using
TPA with placement of a covered stent
GORE®VIABAHN® Endoprosthesis (W.L.Gore,
Newark, DE). On August 17, 2018, patient underwent right common femoral to mid-posterior tibial in situ bypass as there was thrombosis of the
covered stent as well. The runoff arteries were
posterior tibial and peroneal artery though small
in caliber. Open arterial reconstruction was performed on August 17, 2018. Patient developed
surgical site infection and was managed by local
wound care debridement and antibiotics. Two
months later patient developed gangrene of the
right third toe and underwent local amputation.
Because of the non-healing at the amputation site
and duplex imaging of the in situ bypass showing
distal anastomotic stenosis (Fig.94.1), an angioplasty of the distal anastomosis using 2.5mm ×
2cm-long- balloon was performed via left femoral artery approach using 0.014 choice PT wire
on June 28, 2019, with satisfactory completion
run showing less than 10% residual stenosis
(Figs.94.2 and 94.3). The ulceration at the amputation site showed improved healing during subsequent 4 weeks; however the skin edges of the
ulceration started to show ischemic changes in
October 2019 with duplex imaging showing signicant elevation of peak systolic velocity (PSV)
near the distal anastomosis of the in situ bypass.
Patient underwent repeat angioplasty at two sites
of recurrent stenosis in the distal portion of the in
situ bypass with a 6 F pinnacle (45-cm-long)
sheath inserted via left femoral artery approach.
Balloon angioplasty was performed with a 3mm
x 10cm-long balloon with the help of an 0.014
choice PT wire and a Quick-Cross catheter.
Results were satisfactory with <10% residual stenosis (Figs.94.4 and 94.5). Patient began to show
marked improvement in the healing of the amputation site and was last seen on December 9, 2019
(Fig.94.6).
Patient B: History andProcedure
A 75-year-old male had undergone left femoralanterior tibial in situ bypass for gangrene of the
second, third, and fourth toes of the left foot in
April 2015. Patient presented to the hospital in
July 2015 with non-healing ulcer of the left heel.
Duplex imaging of the graft showed severe stenosis of the distal anastomosis of the femoralanterior tibial in situ bypass. It is to be noted that
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_94
425
426
Fig. 94.1 Abdominal aortogram and right lower extremity arteriogram showing patent right femoral poster tibial in situ
bypass (aneurysmal dilatation of vein at proximal anastomosis) and stenosis near the distal anastomosis
94 Angioplasty forFemoral-Tibial inSitu Vein Bypass Stenosis
Fig. 94.2 Angioplasty
near the distal
anastomosis
Patient B: History andProcedure
Fig. 94.3 Less than
10% residual stenosis
427
Fig. 94.4 Patent right
in situ bypass with
recurrent stenosis at two
sites near the distal
anastomosis
428
Fig. 94.5 Angioplasty with less than 10% stenosis
94 Angioplasty forFemoral-Tibial inSitu Vein Bypass Stenosis
Fig. 94.6 Healing of amputation site
anterior-tibial bypass was brought through the
interosseous membrane to be anastomosed to the
proximal segment of the anterior tibial artery.
Patient was taken to the interventional radiol-
ogy suite on July 25, 2015, and the intervention
was initially attempted through the right femoral
artery approach using micro-access technique and
®
insertion of a 5 F sheath. GORE
VIABAHN®
Endoprosthesis marker catheter (AngioDynamics,
Latham, NY) was placed at the aortic bifurcation
and, an angle stiff GLIDEWIRE® (Terumo,
Tokyo, Japan) was advanced into the left common
femoral artery. Left femoral arteriogram revealed
patent left femoral and proximal tibial artery in
situ bypass but with evidence of severe stenosis at
the distal anastomosis (Fig. 94.7). Attempt was
made to advance 6F 45-cm-long Pinnacle sheath
(Terumo) into the left common femoral artery;
however, this was unsuccessful. Using antegrade
puncture of the left femoral (proximal in situ
bypass), sheath was placed. Using 0.014 choice
PT wire and 2.5mm × 4-cm-long balloon, angioplasty was performed on July 25, 2015, with
<20% residual stenosis on completion angiography (Fig.94.8). Patient subsequently underwent
amputation of the left second, third, and distal
portion of the left fourth toe and subsequent healing of the heel ulceration in 6 weeks. Patient was
lost to follow-up until he was admitted on June
20, 2019, from an extended care facility with gan-
Discussion
Fig. 94.7 Femoral anterior tibial in situ bypass showing severe stenosis at distal anastomosis
429
Fig. 94.8 Completion run showing less than 20% stenosis
grene of the left foot with a severe knee contracture. On June 26, 2019, he underwent left above
the knee amputation and was discharged to an
extended care facility 10 days after amputation.
Discussion
Berkowitz et al. reported 12% incidence of
patients who underwent reversed vein bypass.
Patients were managed with percutaneous trans-
luminal angioplasty and open repair. In their
series, most graft stenosis occurred near the proximal anastomosis of the reverse vein bypass
grafts [1]. Carlson etal. performed 45 PTA (percutaneous transluminal angioplasty) in 36
patients for failing infrarenal inguinal bypass
graft from 1990 to 2001. Failing grafts were identied by duplex imaging. They reported technical
success in 91.7% of patients. Stenotic lesions
were identied at proximal anastomosis in 3,
mid-graft in 6, and distal anastomosis in 27
430
94 Angioplasty forFemoral-Tibial inSitu Vein Bypass Stenosis
patients [2]. In their series, reversed in situ and
translocated non-reversed vein bypass grafts
were included. They reported primary patency of
62.7% in 12 months and 58.2% at 24 months.
Cumulated assisted vein bypass graft patency
rates were 83.2% at 12 months and 78.9% at
24 months [2]. Two patients developed thigh
hematomas following PTA with subsequent resolution in a few weeks [2]. They recommend balloon angioplasty of failing infrainguinal bypass
grafts as the initial option and open surgical
repair only in patients if PTA is unsuccessful [2].
Stenosis developing at or near the proximal or
distal anastomosis within 10–12 weeks of the
index operation should preferably be treated with
open repair for fear of anastomotic disruption.
References
1. Berkowitz HD, Fox AD, Deaton DH.Reversed vein
bypass graft stenosis: early diagnosis and management. J Vasc Surg. 1992;15:130–42.
2. Carlson GA, Hoballah JJ, Sharp WJ, Martinasevic
M, et al. Balloon angioplasty as a treatment of failing infrainguinal autologous vein bypass grafts. J Vasc
Surg. 2004;13(39):421–6.
Part XXVII
Endovascular Therapy for Mesenteric
Ischemia
Management ofRadiationInduced Superior Mesenteric
Artery Stenosis withSmall Bowel
Ischemia
95
Physical Examination andHistory
A 70-year-old female presented to the emergency
room of the hospital with abdominal pain of
24hour duration. She had experienced intermittent abdominal pains with vomiting and diarrhea
for the past 12 months. Past surgical history
included distal pancreatectomy for chronic pancreatitis with an incidental nding of adenocarcinoma in the resected specimen of the pancreas.
Patient underwent adjuvant radiation and chemotherapy. Contrast-enhanced CT scan of the abdomen (March 10, 2008) showed an extensive
pneumatosis with portal venous gas (Fig.95.1).
There was evidence of signicant celiac and
superior mesenteric artery (SMA) stenosis and a
small infrarenal abdominal aortic aneurysm
(3.1×3.1cm). There was evidence of fatty liver.
Procedure
Patient underwent visceral arteriogram via left
brachial approach which showed 50% stenosis of
the celiac artery, 80% stenosis of the SMA at its
origin, and inferior mesenteric artery (IMA) occlusion (Fig. 95.2). The 5 F sheath in the brachial
artery was exchanged for a 6F 45-cm-long sheath
Fig. 95.1 CTA abdomen and pelvis pneumatosis of the
small bowel
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_95
Fig. 95.2 Arteriogram showing SMA stenosis, IMA
occlusion, and small AAA
433
434
95 Management ofRadiation- Induced Superior Mesenteric Artery Stenosis withSmall Bowel Ischemia
followed by a 6 F 90-cm-long guiding catheter.
After gaining access into the SMA, using an
exchange length GLIDEWIRE® (Terumo, Tokyo,
Japan) (260-cm-long 0.035mm in diameter). This
wire was then exchanged for a 300-cm-long 0.014
support wire and following a pre-angioplasty with
a 4mm×4cm SAVVY® balloon (Cordis, Hialeah,
FL) with deployment of a 7mm×39mm balloonexpandable PALMAZ GENESIS® stent (Cordis).
As the stent did not extend proximally to the origin
of the SMA, another overlapping 7 × 18 mm
balloon- expandable stent was deployed (Fig.95.3).
Patient was immediately taken for exploratory
laparotomy by general surgery, and an ischemic
terminal ileum and cecum were resected without
anastomosis. Patient was brought back to the operating room 24hours later, and an end-to-end anastomosis of the resected ileum to the ascending colon
was performed, and another 3 inches of ileum and a
small portion of the ascending colon were removed
secondary to ischemia. Following the procedure,
patient developed left brachial artery thrombosis
and underwent left brachial artery thrombectomy
with resection of 1 cm segment of the brachial
artery with end-to-end anastomosis. Patient recovered following a prolonged stay in intensive care
unit (7days) and a total stay of 14days in the hospital. Patient was readmitted with ndings suggestive
of small bowel obstruction on June 30, 2008, and a
non-operative management with nasogastric suc-
tion and uid resuscitation with correction of electrolytes was started. Patient underwent exploratory
laparotomy on July 4, 2008, as there was no
response to non-operative management. Release of
small bowel obstruction due to stricture of the small
bowel 6 inches proximal to the previously sutured
bowel anastomosis was performed, and a Groshong®
catheter (C.R. Bard, New Providence, NJ) was
inserted. CTA of the abdomen showed SMA stent
thrombosis (Fig.95.4).
Fig. 95.4 CTA (lateral view) occluded SMA stent
Fig. 95.3 SMA stenting with two overlapping stents