Distal Common Femoral Artery Research Articles

A novel bailout technique using myocardial biopsy forceps to grasp a dislodged angio-seal collagen with footplate

BackgroundHemostatic devices are now frequently used in femoral artery punctures, and the Angio-Seal (Terumo, Tokyo, Japan) is one of the most commonly used devices for closure of the femoral artery because it provides rapid hemostasis. Although device failure rarely occurs, if the collagen falls into the femoral artery, it may lead to severe limb ischemia. Herein, we describe a case of a novel endovascular technique for the treatment of Angio-Seal arterial closure device failure.Case presentationThe patient in Case 1 was a 75-year-old man with severe left limb claudication. We used a contralateral antegrade approach and used the Angio-Seal for hemostasis. However, the Angio-Seal collagen and footplate dropped and stopped at the bifurcation of the superficial femoral artery and deep femoral artery. The collagen with the footplate was caught with myocardial biotome forceps (MBF) and pulled into the external iliac artery (EIA). The distal common femoral artery (CFA) was punctured, and we delivered a 10.0- × 80-mm stent (SMART®; Cordis, USA) to the EIA from the ipsilateral sheath. The stent was deployed at the EIA and crushed the collagen. The patient in Case 2 was an 88-year-old man with rest pain in the right limb. The right CFA was punctured using an ipsilateral approach and the Angio-Seal was used for hemostasis. The Angio-Seal collagen with the footplate dropped into the bifurcation of the deep femoral artery. The collagen and footplate were caught with MBF and pulled up to the EIA. The right CFA was punctured and a 10.0- × 60-mm stent (SMART®; Cordis) was delivered from the ipsilateral sheath. The stent was deployed at the EIA and crushed the collagen with the footplate.ConclusionsMBF were used to grasp the dislodged collagen with the anchor and cover it with a stent at the iliac artery. This may be a useful bailout technique for Angio-Seal dislodgement.

Endovascular Approach to Complex CTO Lesion in a Poor Surgical Candidate

Despite the various uses of endovascular and surgical techniques in management of patients with critical limb ischemia (CLI), traditional open bypass surgery with vein graft was shown to be more durable in the long term in long segment and heavily calcified lesions per the Best-CLI trial. However, patients with extensive cardiovascular risk factors and poor surgical candidates benefit from an endovascular approach. Endovascular revascularization of long segment lesions is complex and often requires the use of multiple unique techniques. Here, we present a case of a 76-year-old male with complex cardiovascular history with history of partial amputation of the right great toe and fifth toe who presented with non-healing ulcers overlying the right first and fifth distal metatarsals. A 76-year-old man with complex cardiovascular history presented with limited mobility, rest pain, and non-healing ulcers overlying the right first and fifth distal metatarsals. Bilateral common femoral artery (CFA) endarterectomy and lower left extremity angioplasty with stenting was done in the past. Doppler studies demonstrated dampened and flat pulses throughout the right lower extremity. Current computed tomography angiography (CTA) showed occlusion of the right superficial femoral artery (SFA) from the ostium to the P3 segment of the popliteal artery with significant calcification. Through ultrasound-guided left CFA access, a .035 guidewire and sheath were advanced into right distal CFA/proximal SFA and with angiogram confirming CTA results. Through the ultrasound-guided right PTA access and double flossing technique, retrograde V-18 guidewire was advanced into the antegrade Navicross catheter positioned within the right CFA. Subsequently, over the guidewire orbital atherectomy and balloon angioplasty were performed from the distal CFA to the proximal ATA region. With use of intravascular ultrasound for vessel diameter measurement, self-expanding stents were placed from the proximal SFA to the distal popliteal region. Final angiogram demonstrated an improvement of luminal diameter with less than 30% stenosis through the right lower extremity. Patient was started on Xarelto and aspirin. Multimodal endovascular technical approaches such as double-crossing flossing technique, controlled antegrade and retrograde tracking (CART) and reverse CART technique, and synapse rendezvous technique help with management of complex long segment occlusions. The case above demonstrates the use of double-crossing flossing technique in successful revascularization of a patient with end-stage CLI.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The \u201cFracking\u201d technique: a novel approach to crack deep calcified plaque in the common femoral artery with hydraulic pressure

BackgroundThe patency achieved by conventional peripheral interventions for atherosclerotic lesions in the common femoral artery (CFA), called the “no stenting zone”, is not superior to that achieved by surgical endarterectomy due to calcified plaque occupying the area. Plaque modification strategies to obtain acute gain in CFA patency provide the better clinical outcomes than standard balloon angioplasty. Atherectomy devices, which focus on the modification of superficial calcifications, contribute to the improvement of clinical outcomes. However, deep calcifications resist vessel expansion such that luminal gain is not easily achieved.Main textWe propose a novel calcified plaque modification technique, named the “fracking technique” (FT). The term fracking refers to how a rock is fractured by the high hydraulic pressure. In this technique, deep calcifications are cracked with hydraulic pressure via a balloon indeflator through an 18-gauge needle, which punctures calcifications to achieve greater acute luminal gain. Case 1 involved an 81-year-old male with eccentric calcified plaque in the right CFA. Conventional balloon angioplasty for the lesion yielded a suboptimal minimal lumen area (MLA), which increased from 6.2 to 10.7-mm2 on intravascular ultrasound (IVUS). The FT was implemented to obtain a larger MLA. After the FT was repeated at three locations at up to 8-atm, a greater MLA of 27.1-mm2 was achieved without complications. Case 2 involved a 72-year-old male undergoing hemodialysis due to diabetes mellitus who presented with ischemic pain in his right limbs at rest due to severe stenosis with eccentric calcification in the distal CFA. The MLA on IVUS before and after balloon angioplasty was 10.0-mm2 and 13.1-mm2, respectively, and this result was still suboptimal. The FT was attempted and successfully yielded a greater MLA of 28.9-mm2 without complications. Restenosis has not been detected for 2 years follow-up period.ConclusionsThe FT is an effective option for treating calcified CFA lesions to achieve a larger lumen area. Long-term follow-up studies are necessary.

The \u201cNeedle bypass\u201d technique: Percutaneous anatomical bypass with needle rendezvous for patients with peripheral arterial disease that have no other surgical options

BackgroundThe ideal method for recanalization of complex peripheral lesions has not been determined, despite the use of the latest endovascular devices. We describe a novel method for a fully percutaneous anatomical bypass, named the “needle bypass” technique, for treatment of complex vascular lesions with failed previous surgical therapy.Main textA 68-year-old male patient with chronic limb-threatening ischemia presented to our department. He previously had received surgical treatment 10 years prior that included the removal of the right distal common femoral artery and two surgical bypasses, an axillary-femoral bypass and an iliofemoral bypass, because he had repeated infections. He was referred to our center in order to have peripheral interventions. Since the previous conventional bridging/revascularization of the removed common femoral bifurcation had failed, the “needle bypass” technique was then used. With this novel technique, the tips of two percutaneous and bidirectional inserted needles were aligned (“needle rendezvous”) for the externalization of a guidewire in a through-and-through manner. Once this was achieved, an endovascular stent graft and an interwoven stent were deployed to cover and connect the lesion. This new technique is a minimally invasive anatomical bypass that directly connects artery to artery without any disturbance of the venous flow, and this technique, as the only option available, was performed successfully in our no-option patient.ConclusionsThe “needle bypass” technique is an effective percutaneous treatment method in patients with no other surgical options.

Direct bare metal needle puncture and balloon angioplasty in calcified plaques of the common femoral artery guided by angiography (\u201cBAMBOO SPEAR\u201d)

BackgroundSurgical endarterectomy for common femoral artery (CFA) disease is still considered the gold standard for treatment. Development of various techniques and devices has improved the clinical results of endovascular therapy (EVT) for CFA. However, severe conditions remain, especially for occlusive lesions owing to calcified plaque. We developed a useful technique for passing a lesion by directly penetrating the calcified plaque of the CFA using a bare metal needle and then passing through a balloon or dilating it. We named this technique “direct bare metal needle puncture and balloon angioplasty in calcified plaques of the common femoral artery guided by angiography” or “BAMBOO SPEAR.”Main textThis report describes our technique for crossing a lesion by directly penetrating the calcified plaque of the CFA using a needle. We report a case of a 73-year-old male with hemodialysis who presented with cyanosis and ischemic rest pain of both lower limbs. Control angiography showed total occlusion of the left CFA with a calcified plaque. We advanced a 21-G metal needle that was slightly curved into the blood vessel from where the lumen of the distal CFA was located. The needle was advanced into the center of the calcified plaque, while observing from multiple directions with a fluoroscopic guide. We succeeded in advancing the needle into the lumen of the distal external iliac artery. After guidewire crossing, intravascular ultrasound (IVUS) showed that guidewire was able to completely pass through the center of the calcified plaque. We could dilate the lesion by scoring balloon and drug-coated balloon. The final angiography showed sufficient results. We named this technique “direct BAre Metal needle puncture and BallOOn angioplaSty in calcified PlaquEs of the common femoral ARtery guided by angiography” (BAMBOO SPEAR).ConclusionsThe BAMBOO SPEAR technique may be considered a useful option in EVT for occlusive CFA with calcified plaques.

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications.

The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof. Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected. A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m2. The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection. ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.

Experience with Eversion Endarterectomy of the Common Femoral Artery with Comparison to Standard Endarterectomy with Patch

In this retrospective study, we review the outcome of femoral eversion endarterectomy (EE) and standard endarterectomy with patch angioplasty (SEP) over a 10-year period. EE technique involves transection of common femoral artery (CFA), eversion endarterectomy of the distal CFA, and primary end-to-end reconstruction. One hundred forty-two patients underwent femoral endarterectomy, among which 38 (26.8%) endarterectomies were performed using the eversion technique. The cumulative 2-year primary patency of EE with or without a concurrent procedure was greater than 86% and did not statistically differ from SEP. EE is a feasible technique when the use of a patch needs to be avoided.

A case report of atrial myxoma presenting with systemic embolization and myocardial infarction

BackgroundCardiac myxomas are the most common benign primary tumour of the heart. Clinical presentation is variable and ranges from constitutional symptoms to clinical features due to intracardiac obstruction, such as mitral stenosis, coronary embolization, or systemic embolization. Surgical resection is the only effective treatment to prevent its debilitating and catastrophic complication.Case summaryA 61-year-old woman presented with an-hour history of bilateral leg pain, numbness, lightheadedness, dyspnoea, and diaphoresis. Physical exam was remarkable for pale and cold lower extremities. Arterial pulse was not palpable in the right femoral, popliteal, and posterior tibial and dorsalis pedis arteries bilaterally. Electrocardiogram demonstrated normal sinus rhythm with T-wave inversion in lead I, V2, V3, and V4. Laboratory investigations were remarkable for leucocytosis and elevated troponin. Computed tomography angiogram showed emboli with acute infarcts involving the spleen and kidneys, acute embolic occlusion of right external and internal iliac arteries, and left distal common femoral artery. She underwent emergent bilateral cut-down and femoral artery thrombectomies. Transthoracic echocardiogram demonstrated wall motion abnormalities. Computed tomography angiography of the chest revealed an atrial mass and transoesophageal echocardiography was obtained which confirmed an atrial myxoma. Coronary angiography demonstrated no significant coronary artery disease, raising the possibility of myxoma embolization to the coronary arteries as the cause of her troponin elevation and wall motion abnormality. Subsequently she underwent successful resection of the atrial myxoma.DiscussionThe majority of cardiac myxomas are sporadic and arise from the left atrium as an isolated lesion in middle-aged women. Echocardiography is the diagnostic procedure of choice. The long-term survival after surgical resection is excellent and recurrence is rare.

Femoral Balloon-Oriented Puncture for True Lumen Reentry in the Common Femoral Artery After Subintimal Retrograde Recanalization of Superficial Femoral Artery Ostial Occlusion: The FORLEE Technique

Purpose: To report a new technique to reenter the common femoral artery (CFA) true lumen after retrograde recanalization of a superficial femoral artery (SFA) with flush ostial occlusion. Technique: The technique is demonstrated in a 76-year-old woman with critical limb ischemia previously submitted to several surgical revascularizations. A duplex ultrasound showed flush ostial occlusion of the SFA and patency of the anterior tibial artery at the ankle as the sole outflow vessel. After unsuccessful antegrade attempts to recanalize the SFA, a retrograde guidewire was advanced subintimally up to the CFA, without gaining reentry. A balloon catheter was inflated in the subintimal plane across the SFA ostial occlusion. Antegrade access to the distal CFA was achieved with a 20-G needle, which was used to puncture the balloon. A guidewire was advanced into the balloon and pushed forward while the collapsed balloon was pulled back to the mid SFA. The antegrade guidewire was externalized through a retrograde catheter, which was pushed in the CFA true lumen. A retrograde guidewire was advanced and externalized through the femoral sheath, establishing a flossing wire. The procedure was completed in antegrade fashion. Conclusion: The FORLEE technique is a cost-effective option to gain the CFA true lumen after subintimal retrograde recanalization of an ostial SFA occlusion.

Severe Takayasu Arteritis Complicated by Mesenteric Ischemia

Takayasu arteritis (TA) is an idiopathic large vessel vasculitis which occurs mostly in young Asian females. The authors report an atypical presentation of TA in a woman who presented with signs and symptoms of limb claudication and mesenteric ischemia. This case illustrates the potential severity of this disease and the difficulty in its diagnosis and treatment. A 46-year-old Caucasian woman was admitted to the hospital with right lower limb claudication, aroused for small distances, in association to ischemic ipsilateral foot ulcers. She also reported recurrent episodes of abdominal pain, vomiting and diarrhea which leaded to an overall weight loss of 10 kg in a period of a year. Non-invasive vascular testing revealed a right ankle-brachial index of 0.17 and a left ankle-brachial index of 0.37. The abdominal aortography and the computed tomography (CT) angiography showed an occlusion of the superior mesenteric artery and irregularities of the aortic lumen. Oclusions in the right internal iliac artery and in the distal common femoral artery were found in the pelvic aortography. Lower limbs arteriography revealed multiple stenoses. The histological result from the femoral endarterectomy was consistent with large vessel vasculitis. The diagnosis of TA was established according to the American College of Rheumatology Criteria, based on the patient’s symptoms, physical and imaging findings. Despite aggressive immunosuppressive therapy with prednisolone and infliximab, an atypical refractory massive mesenteric ischemia occurred, leading to patient’s death. TA is a rare disease with variable presentation. Since this disease is associated with high morbidity and mortality, an early diagnosis is essential for the best prognosis. Critical mesenteric ischemia and peripheral limb ulcers are rare presentations. As mesenteric ischemia can be potentially fatal, early aggressive immunosuppressive therapy and resection of the affected bowel segment are usually required. J Med Cases. 2017;8(12):383-387 doi: https://doi.org/10.14740/jmc2945w

Retrograde Use of Frontrunner Catheter in Superficial Femoral Artery for Flushing Long Segment Occlusions Involving Distal Common Femoral Artery

We present the case of an 81-year-old female with flush occlusion of the superficial femoral artery (SFA) and percutaneous transluminal angioplasty. Initially, the antegrade approach failed due to flush occlusion without stump. Hard, round surfaced, calcific, and eccentric plaque of the ostium of SFA was also present, which involved distal common femoral artery (CFA). Thus, we successfully used a Frontrunner catheter for retrograde reentry at the lower position of the CFA. Various treatment strategies involving Frontrunner and atherectomy devices could make percutaneous procedures possible in femoropopliteal occlusive disease, involving the CFA.

Loss of bifurcation patency after cross-over stenting of ostial lesions in superficial femoral artery: possible causes, prevention and reintervention

Crossover stenting across the origin of the profunda femoral artery (PFA) and occasionally into the common femoral artery (CFA) is commonly used after suboptimal balloon angioplasty of ostial occlusive lesions of the superficial femoral artery (SFA) involving the bifurcation. Late stent occlusion at the bifurcation is not rare and results in severe lower extremity ischemia. Therefore, we tried to assess its possible causes, prevention and reintervention. Using a prospectively maintained single-center database, 12-month femoral bifurcation patency was retrospectively compared and lesion and procedural predictors of stent occlusion were determined among 63 patients (64 lesions) who between July 2011 and February 2013 underwent crossover (36 non-jailed and 15 jailed SFA, and 12 distal and 1 complete CFA) stenting of de novo ostial SFA lesions. Twelve-month overall patency rate at the femoral bifurcation was 88%, with no significant difference between jailed-ostial SFA (80%) and distal CFA (67%) stenting (P = 0.731), and significant differences between either and non-jailed ostial stenting (100%, P = 0.035 and 0.002). When PFA ostium was jailed by the stent, patients with preexisting CFA or PFA lesions had a 12-month bifurcation patency rate of 20%, significantly lower than those with simple ostial SFA lesions (83%, P = 0.015). Stent induced intimal hyperplasia caused bifurcation occlusion in 6 surgical reintervention cases. In crossover stenting of ostial lesions in SFA, bifurcation patency loss was significantly higher in distal CFA and jailed ostial SFA stenting than non-jailed ostial SFA stenting. Preexisting CFA or PFA lesion is a significant risk factor for bifurcation patency loss when PFA ostium is jailed by crossover stenting.

Deployment of self‐expandable stents for complex proximal superficial femoral artery lesions involving the femoral bifurcation with or without jailed deep femoral artery

To (1) compare the outcome of self-expandable stents with versus without jailed deep femoral artery (DFA) for proximal superficial femoral artery (SFA) lesions, and to (2) ascertain the fate of jailed DFA. Complex SFA lesions involving the femoral bifurcation (FB) was mostly treated surgically, and the role played by endovascular procedures is uncertain. We retrospectively identified 104 consecutive, de novo lesions involving the SFA ostium, stented between April 2005 and September 2010. Depending on the proximal stent edge location, the sample was divided between 60 distal common femoral artery (CFA) stenting with jailed DFA and 44 ostial SFA stenting without jailed DFA. The FB was the segment beginning in the distal CFA, 10 mm proximal to the DFA ostium and ending in the SFA and 10 mm distal to the carina. Stented CFA lesions proximal to the FB were excluded. The bifurcation was classified as patent when free of restenosis and repeat revascularization. The overall 12-month bifurcation and primary patency rates were 72.5% and 52.0%, respectively. Predictors of loss of bifurcation patency were ostial SFA stenting and a small stent in the FB. Bifurcation patency (83.3% vs. 56.3%; P < 0.01) and primary patency of the SFA (56.2% vs. 37.5%; P = 0.088) were higher after distal CFA than after ostial SFA stenting. In 95.7% of distal CFA and 100% of ostial SFA stenting, DFA remained patent at 12-month follow-up (P = 0.237). The 12-month fate of jailed DFA after distal CFA stenting was acceptable, and the bifurcation patency rate was higher than after ostial SFA stenting.

Needle Embolisation to the Right Ventricle: Multiple Complications in a Complex Patient

IntroductionThe communal and repeated use of injection needles predisposes injecting drug users to several complications. ReportThis case report describes uncommon cardiac and pulmonary complications in a 44-year old male, injecting drug abuser. The retention of fractured injection needles in the groin, and the subsequent embolisation to the right ventricle, predisposed to recurrent systemic infections, and cavitating pulmonary septic emboli and pleural empyema as well as local complications. Years later, the needle was completely embedded in the wall of the right ventricle and not suitable for transvenous removal. DiscussionContinuing intravenous drug abuse with injections into the groin result in infective complications, commonly pseudoaneurysms of the distal common femoral artery requiring triple femoral ligation. The embolisation of a fractured injection needle to the RV is a clinical rarity.

Results of polytetrafluoroethylene-covered nitinol stents crossing the inguinal ligament

Placement of arterial endoprostheses across the inguinal ligament is generally thought to be contraindicated for fear of device kinking, fracture, or occlusion and possible obliteration of the deep femoral artery (DFA). We present a series of selected patients who underwent insertion of polytetrafluoroethylene-covered nitinol stents (Viabahn stent grafts. W. L. Gore and Associates Inc, Flagstaff, Ariz) crossing the middle common femoral artery (CFA) on an emergency basis or who were considered high risk for open surgery. We treated 16 patients with 17 lesions adjacent to or within the CFA with stent grafts that originated in the common iliac (two) or external iliac (15) artery and terminated in the distal CFA (12), DFA (three), or superficial femoral (two) artery. Stent grafts were placed on an elective (10) or emergency (seven) basis for arterial occlusive disease (10), bleeding (six), and aneurysmal disease (one). Comorbidities favoring endovascular treatment were high medical risk (10) previous scarring (four), morbid obesity (two), and dense arterial calcification precluding open surgical repair (one). The DFA was deliberately sacrificed in one of the 17 cases. No patient suffered major complications after the procedure. All grafts remained patent based on duplex ultrasound imaging during follow-up (mean, 12.3 months; range, 1-58 months). Two patients required an additional endovascular intervention to treat inflow or outflow stenoses during follow-up, yielding a 2-year primary patency rate of 93.8% and assisted primary patency rate of 100%. These results suggest that selective placement of Viabahn stent grafts across the inguinal ligament to treat arterial occlusive disease or bleeding may prove to be safe, effective, and associated with acceptable patency rates. This strategy helps avoid complicated open arterial surgery in high-risk patients with associated multiple medical risk factors or hostile scarred groins.

Infrascrotal, Perineal, Femorofemoral Bypass for Arterial Graft Infection at the Groin

Infrascrotal, perineal, femorofemoral bypass is an acceptable procedure for treating infection of a prosthetic arterial graft limited to a unilateral groin. A consecutive sample clinical study with a mean follow-up of 29 months. The surgical department of an academic tertiary care center and an affiliated secondary care center. Nineteen patients with a mean age of 68 years with prosthetic graft infection at the outflow anastomosis on a femoral artery at the Scarpa triangle underwent an infrascrotal, perineal, femorofemoral bypass, with excision of the graft material limited at the groin. The recipient artery was the profunda femoris artery in 12 cases, the superficial femoral in 5, and the distal common femoral artery in 2. Cumulative survival, recurrence of sepsis, primary graft patency, and limb salvage rates expressed by standard life-table analysis. Postoperative mortality rate was 5%. Cumulative (SE) survival rate was 65% (11.6%) at 3 years. Cumulative (SE) rate of freedom from recurrent sepsis was 88% (8.6%) at 3 years. Cumulative (SE) primary patency and limb salvage rates were 86% (9.4%) and 91% (7.9%), respectively, at 3 years. Femorofemoral bypass with an infrascrotal perineal approach is a valuable procedure for the treatment of femoral arterial graft infection limited at a unilateral groin.

Diagnosis and Ultrasound-Guided Repair of an Iliac Artery Dissection

Introduction Although contrast arteriography (CA) has historically been considered the gold standard for imaging of the lower extremity arteries, it has known limitations and complications. Duplex ultrasound (DU) imaging has emerged as a viable, and in some instances superior, alternative to CA. The following case study describes the use of DU to diagnose and treat an iliac artery dissection not appreciated by conventional multi-planar contrast arteriography. Case Report The patient is a 46-year-old man with a significant smoking history and symptomatic peripheral vascular disease who has undergone percutaneous transluminal coronary angioplasty and stent placement after a myocardial infarction. He presented with complaints of progressively worsening right leg claudication. The workup included a duplex arterial mapping performed prior to diagnostic CA. DU revealed a short segment right superficial femoral artery (SFA) occlusion and normal Doppler flow characteristics in the common femoral artery. Arteriography confirmed the presence of the SFA occlusion. A follow-up duplex to rule out a groin pseudoaneurysm was then performed. This study revealed no pseudoaneurysm but identified a dissection extending from the mid external iliac artery (EIA) to the distal common femoral artery that was not appreciated by CA. Because of the DU findings, intraoperative CA to evaluate the EIA was performed at the time of SFA endarterectomy and patch angioplasty. Again, the dissection was not evident, and as a result of the inconclusive arteriogram, ultrasound was used intraoperatively to image and facilitate its repair. A 9 × 40-mm SMART stent (Cordis®, Warren, NJ) was deployed in the EIA under ultrasound guidance to seal the leading edge of the dissection. Completion DU showed sealing of the origin of the dissection and near-complete elimination of flow in the false lumen. Conclusions DU diagnosed an EIA dissection that was not detected on CA and was subsequently used as the sole imaging modality to guide deployment of a stent for its repair. This case illustrates that duplex evaluation can be superior to arteriography for both the diagnosis and treatment of patients with peripheral arterial disease.

Catheter for conversion of retrograde to antegrade femoral artery catheterization.

The catheter has a double curve and is triangular (Cook Inc., Bloomington, IN). The primary curve is about 135#{176} and the secondary curve is about 30#{176} (Fig. 1). The common femoral artery is punctured in the retrograde direction at a 70#{176} angle with a Seldinger needle. The catheter is introduced over a guidewire into the abdominal aorta. The tip of the catheter is then engaged into a visceral artery and by a rotational and pushing motion ofthe catheter at the groin, the triangular shape ofthe catheter is re-formed. The catheter is then brought down into the common and external iliac arteries with its tip facing the lateral wall. This avoids opening the catheter loop at the aortic bifurcation or catheterization of the ipsilateral hypogastric artery. In the external iliac artery, the catheter is rotated so as to direct the tip medially. The catheter is then pulled at the groin to engage the secondary curve at the puncture site in the common femoral artery. A test injection of contrast medium usually delineates the distal common femoral artery and the superficial and deep femoral arteries. Road mapping facilitates subsequent passage of a guidewire into the superficial femoral artery. The use of a tapered guidewire decreases the risk of dislodging the catheter out of the femoral artery or pushing the catheter in the retrograde direction into the external iliac artery. This catheter or any other sheath/catheterthen can be passed into the superficialfemoral artery.