Proximal Superficial Femoral Artery Research Articles

A latent bleeding complication in ipsilateral common femoral puncture involving delayed diagnosis: a case report

BackgroundThe trans femoral ipsilateral approach is often adopted for endovascular treatment (EVT) for better steerability of guidewires or better device deliverability. However, contrary to the trans femoral contralateral approach, ipsilateral antegrade puncture sometimes causes peculiar bleeding complications.Case presentationA 76-year-old female underwent EVT for chronic occlusion of the left superficial femoral artery (SFA) via the ipsilateral antegrade approach. After guidewire passage, we inflated the drug-coated balloons, but angiography showed blood flow stasis at the mid segment of the SFA. We also ensured prolonged balloon inflation, which resulted in favorable blood flow. While trying to ensure hemostasis, the blood pressure remained decreased, but neither bleeding nor superficial hematoma were observed at the puncture site. After hemostasis was achieved, we removed the surgical drape and noticed a swelling in the mid-portion of the thigh, distant from the puncture point. We then approached the left common femoral artery (CFA) contralaterally. Angiography showed continuous bleeding from a little bit distally to the sheath insertion point that was spreading through an intramuscular space. We stopped the bleeding with balloon tamponade inside the CFA. Angiography after hemostasis demonstrated blood flow stasis at the mid-segment of the SFA, similarly as that seen before. We confirmed compression of the SFA by a large hematoma using both intra- and extra- vascular ultrasound. Therefore, we deployed a self-expandable stent at the compressed SFA position. Finally, we achieved favorable blood flow on angiography.ConclusionWe encountered a case that latent bleeding unrecognized in the surgical field persisted while prolonged inflation of DCB was conducted at just proximal SFA. We could have avoided bailout stenting by noticing the bleeding incident in a timely manner. Prediction and prevention are essential for all kinds of procedural complications in EVT.

An ultrasound-based femoral artery calcification score

ObjectiveDuplex ultrasound (US) of the lower extremities is commonly used to assess patients with lower extremity atherosclerosis. Arterial calcification can often be visualized in these images; however, efforts to quantify its extent have been limited. We, thus, sought to develop a new scoring system to measure calcification on duplex US studies of the femoral artery and correlate it with standard computed tomography (CT)-based methods. We then made preliminary attempts to correlate US-based femoral artery calcification scores with limb-specific outcomes in patients with peripheral arterial disease. MethodsPatients who underwent CT evaluation of the lower extremities and arterial duplex US of either lower extremity within 6 months of each examination were included in the study. CT-based calcium scores of the femoral artery were generated using calcium scoring software. To determine the US score, five standard arterial segments (ie, common femoral artery, proximal superficial femoral artery [SFA], mid-SFA, distal SFA, and above the knee popliteal artery) were scored using a scale of 0 to 2 (0, a completely normal vessel segment; 1, a vessel with hyperechoic irregularities of the vessel wall; and 2, clear anechoic shadowing). The available scores were then averaged to yield a single femoral calcium score for each leg. Predictors of femoral calcification scores were then assessed and compared with the CT-based methods. The correlation between the US- and CT-based femoral calcification was assessed, and then the association between the US-based femoral calcification score and limb outcomes was evaluated. ResultsA total of 113 patients met the inclusion criteria and were included in the final analysis. US-based calcification scores were increased in patients with diabetes, renal failure, and the presence of chronic limb threatening ischemia similar to CT-based femoral calcification. The US- and CT-based calcification scores showed a moderate to strong correlation (r = 0.64). An elevated US-based femoral artery calcification score was associated with decreased amputation-free survival. ConclusionsA novel US-based method shows promise as a simple method for quantifying the extent of femoral artery calcification in patients with peripheral arterial disease. The US-based method correlates with standard CT-based methods. Preliminary studies show that it could be useful for predicating outcomes for patients with peripheral arterial disease.

Technique and early results of percutaneous femoropopliteal bypass with stent graft

ObjectiveWe describe the technique and early results of lower extremity revascularization with total percutaneous bypass using extravascular placement of a stent graft (percutaneous prosthetic bypass). MethodsPatients with severe chronic limb threatening ischemia for whom open or endoluminal repair was either not feasible and or had failed were selected for a pilot study using percutaneous prosthetic bypass. The procedure requires placement of three introducer sheaths in the contralateral common femoral artery, and the ipsilateral proximal and distal superficial femoral arteries (SFAs). A guidewire is placed from the contralateral sheath to the ipsilateral popliteal artery via the two ipsilateral sheaths. Two self-expanding polytetrafluoroethylene-covered stents are then placed from the proximal SFA to the distal SFA. ResultsA total of 30 bypasses were performed in 28 patients aged 71 ± 3 years. Of the 28 patients, 16 had severe claudication (Rutherford class 3; 53%) and 14 had critical ischemia (Rutherford class 4-6; 47%). The early results were excellent, with no deaths and one occlusion successfully treated with thrombolysis. No other complications requiring reintervention occurred. The mean follow-up was 25.4 months (range, 3-36 months). The 12- and 36-month Kaplan-Meier survival curve was 100% and 81%, respectively. The primary patency, secondary patency, and freedom from amputation rates were 75% and 75%, 78% and 75%, and 100% and 91%, respectively. ConclusionsFor patients with long lesions and/or failed endovascular treatment, the described technique offers the advantage of a total percutaneous procedure with acceptable early results. If these favorable outcomes are confirmed in larger series with longer follow-up, percutaneous extravascular bypass of the SFA will represent a complementary tool for infrainguinal arterial repair.

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)

Abstract 11126: Longitudinal MRI-Based Superficial Femoral Artery Velocity Measurements in Peripheral Artery Disease: An Analysis of the Effect of Lipid Modification on Peripheral Artery Disease After Endovascular Intervention Trial (ELIMIT)

Introduction: Peripheral artery disease (PAD) causes lower extremity dysfunction and is associated with an increased risk of cardiovascular mortality and morbidity. We analyzed longitudinal associations of non-invasive 2-dimensional-phase-contrast magnetic resonance imaging (2D-PC-MRI) velocity markers of the distal superficial femoral artery (SFA) with characteristics of PAD. Hypothesis: Longitudinal changes in MRI-based measures of SFA velocity are associated with changes in SFA lumen volumes in PAD. Methods: A total of 33 (11 diabetic, 22 non-diabetic) PAD patients, who completed baseline and 2-year follow-up MRI were included in this secondary analysis of ELIMIT. Electrocardiographically-gated 2D-PC-MRI was performed at a proximal and a distal imaging location of the distal SFA territory. SFA lumen, wall, and total vessel volumes were averaged over all distal SFA MRI slices. Results: Baseline characteristics did not differ between diabetic and non-diabetic PAD patients (Table). Proximal and distal SFA velocity measures did not differ between baseline and 2-years (41.98: IQR (23.58, 72.6) cm/s; vs. 40.31: IQR (26.69, 61.29) cm/s; p=0.30, for maximum SFA velocity). The velocity amplitude (defined as the difference between the SFA minimum and maximum velocity) was significantly lower in the distal compared to the proximal SFA location at both baseline and at the 2-year visit (p=0.003, p<0.001). In a pooled analysis of all 33 PAD patients, the 2-year change of the average SFA velocity was significantly associated with the 2-year change in the averaged SFA lumen volume (beta: 0.00011, r 2 : 0.175, p=0.017). In a subgroup analysis, a similar pattern was observed in diabetic patients (beta: 0.00006, r 2 : 0.714, p=0.001), but not in non-diabetics (beta: -0.000019, r 2 : 0.0095, p=0.68). Conclusion: Longitudinal 2D-PC-MRI SFA velocity changes are associated with 2-year SFA lumen changes. 2D-PC-MRI velocity measures may be of interest in assessing PAD.

P01] Eligibility of COmmoN FEmoral Artery AtheroSclerotic DiSease for Endovascular Treatment: The CONFESS Study

<h3>Objective</h3> Despite advances in endovascular technologies, the proportion of common femoral artery (CFA) lesions treated with endarterectomy (CFAE) which would be amenable to endovascular treatment with modern technologies is unknown. This study aimed to describe the morphology and composition of CFA lesions treated with surgical reconstruction in two high volume centres and report the proportion that would be amenable to endovascular treatment. <h3>Methods</h3> All consecutive patients presenting with symptomatic peripheral arterial disease from January 2014 to December 2018 who underwent CFAE were included. Extensive data relating to the anatomy and morphology of the CFA atherosclerotic lesions were collected, including in depth analysis of the composition of the CFA plaque using three dimensional reconstruction based on computed tomography angiography. <h3>Results</h3> A total of 829 CFAs in 737 patients were included (mean age 71 ± 10 years; 526 males, 71%); 451 (62%) presented with critical limb threatening ischaemia. Overall, 271 CFAs (33%) had a severe calcium load (> 1.1 cm³) that would have required stenting; 376 (45%) target vessels had a calcium load < 1.1 cm ³ with a patent CFA, profunda femoral artery (PFA), and proximal superficial femoral artery (SFA) and therefore would have been amenable to less complex endovascular treatment. Four (0.5%) target vessels were characterised by an occlusion of the CFA, external iliac artery (EIA), SFA), and PFA, and 642 (77%) by a patent CFA, PFA, and EIA. <h3>Conclusion</h3> A significant proportion of patients with atherosclerotic CFA lesions who undergo surgery could potentially be candidates for endovascular treatment. A randomised trial comparing CFAE and new endovascular techniques in this clinical context is urgently required.

Endovascular Treatment of a Giant Iliac Vein Aneurysm After a Traumatic Arteriovenous Fistula

A 60 year old man with a history of a military mine injury 30 years previously presented with chronic leg swelling and a non-healing ulcer. Computed tomography angiography (CTA) revealed a giant iliac venous aneurysm (Figure A; red arrow) due to a chronic arteriovenous fistula (green arrows) in the proximal superficial femoral artery (SFA; mine fragments indicated by the blue arrows). An iliac limb stent graft (16 – 23 mm × 100 mm; W.L. Gore & Associates, Flagstaff, AZ, USA) was placed via an open antegrade common femoral artery approach into the SFA.

Magnetic resonance imaging based superficial femoral artery velocity measurements in peripheral artery disease

Peripheral artery disease (PAD) causes lower extremity dysfunction and is associated with an increased risk of cardiovascular mortality and morbidity. In this study, we analyzed how non-invasive 2-dimensional-phase-contrast magnetic resonance imaging (2D-PC-MRI) measured velocity markers of the distal superficial femoral artery (SFA) are associated with clinical and functional characteristics of PAD. A total of 70 (27 diabetic and 43 non-diabetic) PAD patients were included in this secondary analysis of data collected from the Effect of Lipid Modification on Peripheral Artery Disease after Endovascular Intervention Trial (ELIMIT). Electrocardiographically (ECG)-gated 2D-PC-MRI was performed at a proximal and a distal imaging location of the distal SFA. Baseline characteristics did not differ between diabetic and non-diabetic PAD patients. Claudication onset time (COT) was shorter in diabetic PAD patients compared to non-diabetics (0.56 (inter quartile range (IQR): 0.3, 2.04) minutes vs. 1.30 (IQR: 1.13, 2.15) minutes, p = 0.025). In a pooled analysis of all 70 PAD patients, maximum velocity was significantly higher in the proximal compared with the distal SFA segment (43.97 (interquartile range (IQR): 20.4, 65.2) cm/s; vs. 34.9 (IQR: 16.87, 51.71) cm/s; p < 0.001). The maximum velocities in both the proximal and distal SFA segments were significantly higher in diabetic PAD patients compared with non-diabetics (proximal: 53.6 (IQR: 38.73, 89.43) cm/s vs. 41.49 (IQR: 60.75, 15.9) cm/s, p = 0.033; distal: 40.8 (IQR: 23.7, 71.90) cm/s vs. 27.4 (IQR: 41.67, 12.54) cm/s, p = 0.012). Intra-observer variability, as assessed by intraclass correlation (ICC) analysis, was excellent for SFA mean and maximum velocities (0.996 (confidence interval [CI]: 0.996, 0.997); 0.999 (CI: 0.999, 0.999)). In conclusion, 2D-PC-MRI SFA velocity measures are reproducible and may be of interest in assessing diabetic and non-diabetic PAD patients.

Safety and feasibility study of non-invasive robot-assisted high-intensity focused ultrasound therapy for the treatment of atherosclerotic plaques in the femoral artery: protocol for a pilot study

IntroductionPeripheral arterial disease (PAD) is an atherosclerotic disease leading to stenosis and/or occlusion of the arterial circulation of the lower extremities. The currently available revascularisation methods have an acceptable initial...

Risk Factor Analysis for Crossing Failure in Primary Antegrade Wire-Catheter Approach for Femoropopliteal Chronic Total Occlusions

Introduction: Antegrade wire-catheter crossing remains the primary approach for femoropopliteal interventions. Nonetheless, data reporting on crossing failure are limited. Aim of this study is to identify risk factors for antegrade crossing failure in patients with femoropopliteal chronic total occlusions (CTOs). Methods: This is a single-center, retrospective analysis. Patients with femoropopliteal CTOs treated between May 2018 and February 2020 were included into this study. Primary endpoint of this analysis was primary crossing success defined as successful antegrade crossing without the use of retrograde access, crossing or re-entry devices. The assisted crossing success was additionally analyzed. A logistic regression analysis identified risk factors for failed primary antegrade crossing. Results: Data from 300 patients were analyzed. The majority (n=183, 61%) presented with lifestyle limiting claudication. The mean lesion length was 180 mm [interquartile range (IQR) 100–260 mm], whereas the median CTO length was 100 mm (IQR=50–210 mm). A chronic total occlusion crossing approach based on plaque morphology (CTOP) type I configuration was observed in 9% (n=26) of the lesions, type II in 61% (n=183), type III in 8% (n=25), and type IV in 66 CTOs (n= 66, 22%). Severe calcification based on the Peripheral Arterial Calcium Scoring Scale (PACSS), Peripheral Academic Research Consortium (PARC), and 360° grading systems was identified in 17%, 24%, and 28% of the lesions, respectively. A contralateral femoral access was used in 278 cases (93%). The primary crossing success amounted to 70% (n=210). The use of a re-entry device in 28 patients (9%) or of a combined antegrade–retrograde approach in 11% (n=34) of the cases increased the assisted crossing success to 89% (n=267). The presence of calcification (odds ratio [OR]=4.2, 95% CI=1.7–10.2) or of circumferential calcium (OR=2.5, 95% CI=1.3–4.9), a CTOP class ΙΙΙ or ΙV (OR=1.9, 95% CI=1.4–2.6), a proximal superficial femoral artery (SFA) occlusion (OR=3.5, 95% CI=1.7–7.4) and a CTO at P3 (OR=4.1, 95% CI=1.5–10.8) were associated with an increased risk for antegrade crossing failure. Conclusions: In this study, chronic total occlusions (CTO) morphology, calcification burden, and lesion’s location were identified as independent risk factors for failed antegrade crossing. Nonetheless, the use of alternative crossing strategies significantly increased the overall crossing success.

Primary Lower-Limb Arterial Stent Infection Managed with Resection and in Situ Bovine Pericardial Revascularization

Peripheral arterial stent infection is a rare but morbid condition. We present the case of a patient with primary stent infection of his superficial femoral artery (SFA) and popliteal artery, managed with surgical explant and in situ reconstruction using rifampicin-soaked bovine pericardial tube graft. A 69-year-old man presented with a 3-day history of left groin pain. He had had stents placed into his SFA and popliteal artery in 6 months prior. Duplex ultrasound demonstrated a pseudoaneurysm of the common femoral artery (CFA), with ying-yang flow. A computed tomography angiogram confirmed this pseudoaneurysm, which had a thick rind of nonenhancing soft tissue. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. The patient was taken to the operating theater, and the CFA, profunda femoris artery, and SFA were exposed. After heparinization and clamp control, the pseudoaneurysm was incised, which revealed that the proximal SFA had been completely eroded. All infected tissues were resected. In situ arterial reconstruction was undertaken using a rifampicin-soaked bovine pericardium tube graft. A subsequent positron emission tomography scan revealed high fluorodeoxyglucose uptake around the patients remaining distal SFA and popliteal artery stents. These were explanted in the same manner described above. There is limited evidence regarding the prevention of infection when placing peripheral arterial stents. The Society of Interventional Radiology does not recommend routine prophylactic antibiotics when placing peripheral stents. In situ reconstruction using bovine pericardium is a well-described technique in the management of aortic graft infections, but there is limited experience in its use in a peripheral setting.

Infected Pseudoaneurysm with Necrotising Fasciitis Following Femoral Artery Catheterisation

Femoral pseudoaneurysm is the most common complication of femoral artery catheterisation usually diagnosed by colour doppler ultrasound. Ultrasound-guided compression has replaced surgery to be the mainstay of therapy due to its high success rate and low complications. The present case is about a 63-year-old female, who presented with pain and swelling in the right groin. She had undergone coronary angioplasty two weeks back. She developed fever, chills, wound induration and necrosis at the puncture site. A laboratory study revealed leucocytosis, elevated Erythrocyte Sedimentation Rate (ESR), and C-Reactive Protein (CRP). Ultrasound doppler showed a 4×2.8×2.7 cm pseudoaneurysm of the right superficial femoral artery with a to-and-fro flow pattern. Computed Tomography (CT) angiogram showed a large narrow neck pseudoaneurysm arising from the anterior wall of the proximal superficial femoral artery just distal to its origin. The right superficial femoral angiogram showed a pseudoaneurysm draining into a large cavity. She underwent an ultrasound-guided thrombin injection of the pseudoaneurysm. A thrombus was formed in the superficial femoral artery after thrombin injection and thrombosuction was done. The necrotic tissue was excised and skin grafting was done after the wound healed.

Upper thigh loop prosthetic arterio-venous grafts (AVG) for dialysis access: An Indian perspective.

Hemodialysis forms the most common replacement therapy for majority of Indians suffering from chronic kidney disease (CKD). Multiple access failure and central vein stenosis has become commonplace in Indian dialysis access patients and there is a burgeoning need for more advanced hemodialysis (HD) access options. Upper thigh arterio-venous grafts (AVG) are seldom inserted due to fear of infection and limb ischemia. This is a single institutional, retrospective, descriptive case study of consecutive patients who underwent upper thigh prosthetic AVG over a period of 7 years. All these patients had exhausted options of upper limb access and or had central vein stenosis. AVG from the proximal superficial femoral artery (SFA) to the proximal great saphenous vein (GSV) in a loop configuration using polytetrafluoroethylene (PTFE) was carried out in the upper thigh. A total of 24 patients had undergone upper thigh loop AVG. Their age varied from 24 to 77 years. The median follow-up period was 3 years. Five of these grafts developed infection (21%) which led to primary failure. A primary patency of 71% (17/24 patients) was achieved at 1 year. Thrombosis developed at a mean of 16.7 months after the primary procedure. Adjunctive procedures such as thrombectomy, segmental replacement of graft, patch angioplasty, balloon angioplasty, and stenting were required in 75% of patients to achieve a secondary patency of 86% at 1 year. Three grafts were explanted without limb loss. Upper thigh loop AVG forms a reliable alternate dialysis access option for patients with failed upper limb access sites or central vein occlusion. Adjunctive procedures are key to maintaining patency in these grafts. Good secondary patency is achievable, and the infection rates are similar to arm AVG. Close follow-up and timely intervention are key to long term dialysis through these grafts.

Peripheral Vascular Bypass with Cadaveric Arterial Allograft in a Toddler with FemoralMycotic Aneurysm

<h3>Introduction & Objective</h3> Mycotic aneurysms are exceedingly rare in the pediatric population. The optimal surgical treatment for children with this disease is unclear as aneurysm resection and vascular reconstruction are uncommonly performed in young children. We present the unique case of a21-month-old child with a complex cardiac history who presented with leg ischemia and a femoral mycotic aneurysm that was successfully repaired with an external iliac to profunda femoris artery vascular bypass with cryopreserved arterial allograft and femoral vein reconstruction. <h3>Case Report</h3> Our patient presented with leg ischemia and blood cultures positive for <i>Aspergillus</i>, with CT angiography demonstrating complete occlusion of the left common femoral artery and proximal superficial femoral artery (Figure 1Figure 1Axial computed tomography shows large left common femoral artery mycotic aneurysm with dense inflammatory reaction.Figure 1). Upon operative exploration, there was an extremely dense inflammatory response with purulent material extruding from the region and bulky reactive lymphadenopathy (Figure 2AFigure 2A-B. (A) Intraoperative photograph demonstrating large mycotic aneurysm involving the femoral artery. (B) Intraoperative photograph demonstrating the completed anastomosis between the left common iliac artery and the profunda femoris artery, along with femoral vein reconstruction.Figure 2) with extension of thrombosis from the external iliac artery immediately at the inguinal ligament to the superficial femoral artery. The 2 mm profunda arterywas the remaining outflow to the lower extremity. A 6 mm cryopreserved artery allograft (CryoArtery) was used to perform the vascular bypass between the external iliac artery and the profunda femoris artery in an end-to-side fashion. The mycotic aneurysm and underlying vesselswere dissected and resected from the external iliac artery to the proximal superficial femoral artery. As the femoral vein was densely adherent to the inflammatory mass, a segment was removed and reconstructed in a similar fashion with CryoArtery. Completed anastomosis is shown in Figure 2B. At the conclusion of the procedure, the patient had biphasic doppler signal in the dorsalis pedis artery. <h3>Conclusions</h3> Successful vascular reconstruction can be performed in a young child with an Aspergillus mycotic aneurysm using cadaveric arterial allograft. For our patient, a cryopreserved artery allograft was used as the iliofemoral bypass conduit. Although an autologous conduit would have been the preferred bypass method, it was not possible in this case owing to the patients immaturevenous system and prior surgical manipulation. Not only is restoring flow to the distal extremity of the utmost importance in young pediatric patients to avoid future limb-length discrepancies, but flow must also be maintained in the bypass conduit postoperatively without conduit occlusion. Our patient received intravenous heparin in the immediate postoperative period and was bridged to prophylactic enoxaparin for three months and aspirin indefinitely. If the use of an autologous conduit is not possible, we show here that a cadaveric arterial allograft can be a suitable and durable alternative and report the successful vascular reconstruction of a 20-month-old with an Aspergillus mycotic aneurysm using cadaveric arterial allograft and no limb-length discrepancy as of thirty-six months follow-up.

Successful limb salvage beyond the golden time following blunt traumatic open complete transection of the femoral artery and vein in a patient with cardiac arrest: a case report

BackgroundOpen complete transection of the femoral artery and vein following blunt trauma is extremely rare. Furthermore, even if the patient has been successfully resuscitated, it is sometimes difficult in most patients to preserve the injured limb, especially after damage control resuscitation. We report a case of open complete transection of the femoral artery and vein secondary to high-energy blunt trauma and a successful limb preservation treatment strategy.Case presentationA 57-year-old Asian man was transferred to hospital after having fallen from the 15th floor of a condominium. The patient was in cardiac arrest at the scene, but was successfully resuscitated by emergency medical services staff. On arrival, the patient’s hemodynamics were completely collapsed with active external bleeding from the thigh, so we immediately started resuscitation including activation of massive transfusion protocol and temporarily ligated the transected proximal superficial femoral artery, deep femoral artery just distal after branching lateral femoral circumflex artery and the superficial femoral vein. Following radiological findings showing a potential pelvic fracture with active bleeding, we also performed retroperitoneal packing in the resuscitation room and moved the patient to the angiography room for transcatheter arterial embolization. The patient’s consciousness was preserved and perfusion of the injured limb was barely maintained after his hemodynamics were adequately stabilized. As we detected weak perfusion of the lower limb via a potential collateral flow from the lateral femoral circumflex artery branches from deep femoral artery by pulse doppler of the dorsal pedis artery, we decided to reconstruct superficial femoral artery and vein at 24 h after injury using great saphenous vein bypass grafts. The patient was transferred to a rehabilitation hospital with good neurological and limb outcome after hospitalization for 52 days.ConclusionWe successfully preserved the patient’s lower limb after cardiac arrest and complete transection of the femoral artery and vein and achieved a good neurological outcome. Even if a femoral artery needs to be ligated temporarily, careful observation and assessment should be performed so as not to lose the chance to salvage the limb even during damage control resuscitation.

Aneurysmal degeneration of fluoropolymer-coated paclitaxel-eluting stent in the superficial femoral artery: a rising concern

BackgroundAlthough several clinical reports demonstrated a durable patency rate after a novel fluoropolymer-coated paclitaxel-eluting stent (Eluvia; Boston Scientific, Marlborough, MA, USA) placement, aneurysmal degeneration after drug-eluting stent (Eluvia) placement has raised clinical concerns. Here, we report a case with progressive aneurysm formation on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery atheromatous plaque.Case presentationA 79-year-old woman with right leg intermittent claudication at 100 m distance was referred to our hospital. Pre-procedural angiography showed long-segment severe stenosis from the middle-to-distal part of the right superficial femoral artery, and a 7 mm wide drug-eluting stent (Eluvia) was placed. However, the patient had a recurrence of intermittent claudication in the right lower extremity 25 months thereafter. Angiography revealed de novo stenosis in the distal part of the popliteal artery and proximal superficial femoral artery in-stent restenosis. Subsequently, the patient underwent endovascular therapy for these lesions. In addition, intravascular ultrasound at the time of endovascular therapy revealed femoral artery enlargement with a maximum vessel diameter of 10.0 mm at the distal edge of the stent. Intermittent claudication on the right side recurred again 50 months after drug-eluting stent (Eluvia). Angiography demonstrated de novo severe stenosis from the distal part of the superficial femoral artery to the middle part of the popliteal artery. Peri-stent contrast staining was found at the distal part of the drug-eluting stent (Eluvia) site. Intravascular ultrasound showed a further enlargement of maximum vessel diameter to 12.0 mm at the distal edge of the stent.ConclusionsWe report a case with progressive aneurysm degeneration on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery stenosis.

Calcification patterns in femoral and carotid atheromatous plaques: A comparative morphometric study.

This comparative study was designed to focus on the mineral patterns in human atherosclerotic plaques based on quantitative measurements of calcium deposits through the morphometric method. A total of 101 atherosclerotic plaques were harvested by conventional transluminal angioplasty from the carotid artery (CA) and different segments of the femoral-popliteal axis (FPA), fixed in formalin and sent for histological processing. The histological grade of the atherosclerotic plaque and the calcification pattern were evaluated, followed by a morphometric analysis of the mineral deposits. Regarding the localization, the advanced plaques (VII and VIII types) developed predominantly at the level of the superficial femoral artery (SFA) compared to the CA (P<0.001). This significant difference was maintained even if they were divided into low grade (IV and V) and high grade categories (VI, VII and VIII) (P<0.05). Compared with that in the carotid plaques, in the FPA plaques the mineralized surface increased in parallel with the narrowing of the vascular lumen diameter. The image analysis of the total pathological calcification score (pCS) showed a significant difference between the CA plaques and distal SFA (dSFA) plaques (P=0.038) and between the proximal SFA (pSFA) and dSFA plaques (P=0.013). In the case of the simple nodular pattern, calcification occupied significantly larger areas in the plaques developed in the dSFA and popliteal artery (PA) in comparison with the CA plaques (P=0.0007 and P=0.0009). pCSs calculated in plaques with extensive calcification pattern showed a lower value in the CA vs. the pSFA plaques (P=0.004). A less pronounced, but significant difference was observed between the pCS of pSFA and dSFA plaques (P=0.017). Femoral and carotid plaques exhibited different morphology and tendency for calcification. In parallel with the narrowing of the vascular lumen diameter, the mineralized surface increased at the level of different FPA segments. These results suggest that the mechanism is site-specific, and wall structure-dependent.

Remote endarterectomy to remove infected Viabahn stent-graft

Infection of peripheral arterial vascular grafts and stent-grafts represents a complex surgical scenario, with a number of proposed management strategies. Surgical removal of infected material with adjunctive arterial reconstruction is often required. However, surgical removal is often difficult and complex. This case study demonstrates an infected Viabahn stent-graft between the external iliac artery and the superficial femoral artery, with arterial autolysis of the common femoral artery and proximal superficial femoral artery, in which a hybrid technique combining remote endarterectomy and surgical debridement was used to remove the infected stent-graft.

Venous outcomes at 1 year after using the femoral vein as a conduit for passage of percutaneous femoropopliteal bypass

ObjectiveThe DETOUR 1 study was performed to assess the safety of the femoral vein as a "pass through" conduit for covered stent placement during fully percutaneous femoropopliteal bypass, also known as the DETOUR procedure. MethodsAt eight participating centers in this prospective, single-arm, international trial, 78 patients (82 femoropopliteal lesions) were enrolled. All patients had patent femoral veins measuring ≥10 mm in diameter at baseline. The DETOUR procedure involved delivery of a series of TORUS stent grafts, deployed from contralateral common femoral artery access, to the ipsilateral proximal superficial femoral artery, with entry into the femoral vein and re-entry into the arterial vasculature at the above-the-knee popliteal artery. The TORUS stent grafts are deployed in an overlapping configuration as an arterial-arterial conduit. Due to this novel transvenous approach, we assessed specific considerations related to the venous system to analyze the risk of risk of venous thromboembolic complications. Symptomatic deep vein thrombosis, nonocclusive material associated with the graft such as benign endovenous graft-associated material, pulmonary embolism, Venous Clinical Severity Score (VCSS) and Villalta scores, and luminal occupancy by the stent graft were assessed as the ratio of cross-sectional areas of the stent graft to the native vein at baseline and 1 year after the procedure. ResultsA duplicate femoral vein was present in 20.7% of cases. The majority of patients (86.8%) had a femoral vein luminal area preservation of ≥55%. Thirty-two patients experienced an increase in the vein diameter over time after the procedure, but this pattern of venous remodeling was not uniform. The patients who had a compensatory increase in the vein diameter had a smaller average baseline vein diameter compared with the patients who did not have a compensatory increase in vein diameter (P = .0414). Only two patients (2.4%) developed ipsilateral symptomatic deep vein thrombosis) through 1 year of follow-up. There were no pulmonary embolism in any patient in the series. The overall VCSS and Villata scores did not change during follow-up. Mean VCSS and Villata were 0.8 ± 1.4 and 0.5 ± 1.1 at 1 year, compared with 0.6 ± 1.0 and 0.4 ± 0.9 at baseline, respectively. ConclusionsAs a percutaneous alternative to open surgical bypass for complex femoropopliteal peripheral arterial disease, the transvenous bypass has a low rate of deep venous thrombotic and obstructive complications. Cross-sectional vein area is preserved, and in some patients, the compensatory vein diameter increases with time, supporting the feasibility and safety of using the lower extremity deep venous system as a pass-through conduit for the DETOUR percutaneous femoropopliteal bypass. Trial RegistrationNCT02471638.

Safety and efficacy of Mynx vascular closure device for the closure of common femoral artery access after ipsilateral stent placement.

To evaluate the feasibility and safety of the Mynx vascular closure device (VCD) for arteriotomy closure after stent placement near the common femoral artery (CFA) access site. A total of 88 patients (73 men; mean age, 72 ± 9.2 years; 136 procedures) who underwent closure of CFA arteriotomy using the Mynx VCD after stent placement in proximal superficial femoral artery (SFA) with antegrade approach, or in common or external iliac artery with retrograde approach were retrospectively studied. Technical success and access site complication were evaluated. Body mass index (BMI), platelet count, international normalized ratio, prior history of ipsilateral CFA access, access direction, degree of CFA calcification, stent location and diameter, total procedure time, and sheath size were analyzed to evaluate their relationship with technical failure and development of bleeding complications. Technical success was achieved in 94.9% (129/136) patients. The mean time to hemostasis was 0.7 ± 1.8 min. Technical failure was significantly associated with low BMI (p = 0.001). Other variables presented no significant relationship with technical failure and development of complications. Ultrasonography on the day after the procedure revealed that 8 (5.9%) patients had hematoma. Mynx VCD for arteriotomy closure is feasible and provides hemostatic safety after stent placement near antegrade or retrograde CFA access. However, Mynx VCD may have a poor technical success rate among patients with low BMI.