IVUS Directed Stent Placement Decision in a Hybrid Procedure for Lower Limb Revascularization. is Angiography Enough?

Abstract

Introduction: The decision of wether to implant a stent or not after endovascuar angioplasty of the Superficia femoral artery (SFA) is clasically based on arteriographic control. Neverthless, the angiographical signs in which stent implatation indication is based are subjective and unccurate. Intravascular ultrasound (IVUS) is an intraopertive, readily availabel tool that can help to decide when angiography is unconclusive. We present a case report in which IVUS confirmed a postangioplasty dissection with critical residual stenosis inadvertent in angiography. Methods: A 56 year old male patient with Rutherford 5 lower limb ischemia underwent hybrid revascularization consisting in surgical endarterectomy of the common femoral artery and endoavascular treatment of the SFA and anterior tibial artery. A very calcified short lesion at the SFA was initially dilated with plain balloon angioplasty, without evident residual stenosis and good outflow in angiographic control, but with turbulent flow at the treated segment. IVUS confirmed critical residual stenosis secondary to intimal dissection, indicating stent implantation. Stent dimensions were decided based on measurements obtained with IVUS, which helped to identify the length and diameter of the dissected arterial segment. Complete expansion of the stent was also assesed by IVUS control. Results: The patient recovered pedal pulse immediatelly after the procedure. 3 Months after revascularization all whounds at the foot had healed, without rest pain and complete patency of all the arterial treated segments assesed by dupplex ultrasound. Conclusion: Angiographic control after angioplasty of complex lessions at the SFA is sometimes misleading, avoiding detection of local complicactions at the treated segment and jeopardizing short term patency results of endovascular procedures. IVUS provides crucial additional information when deciding whether or not to implant a stent, and could become an essential tool for these procedures in the future, even displacing arteriography as a the gold-standard for post-angioplasty control image.