Superficial Femoral Artery Occlusion Research Articles

Successfully Treated Femoral Artery Thrombosis in a Patient with Minimal Change Nephrotic Syndrome

In contrast to widely recognized venous thrombotic complications, peripheral arterial thrombosis as a complication of nephrotic syndrome, especially without preceding iatrogenic venous puncture, corticosteroid treatment, or coagulation factor abnormalities, has rarely been reported in adult female patients. We report the case of a 39-year-old woman who presented with pain in the right lower leg accompanied by minimal change nephrotic syndrome. Lower-extremity angiography showed total occlusion of the right superficial femoral artery. Thrombectomy was performed with a balloon catheter, and the thrombi were successfully aspirated. Our experience indicates that even if few traditional risk factors for atherosclerosis are identified, a high index of suspicion and aggressive treatment of arterial thrombosis in adult nephrotic syndrome are crucial to minimize serious ischemic injuries.

Crush implantation of a self-expanding interwoven stent over a subintimally recanalized standard stent in a TASC D lesion of the superficial femoral artery

We demonstrate feasibility of implantation of a self-expanding interwoven nitinol stent in a claudicant, where recanalization attempt of a heavily calcified, occluded superficial femoral artery (TASC D lesion) was complicated by a previously implanted, fractured standard stent. Wire passage through the occlusion and beyond the fractured stent could only be achieved through the subintimal space. A dedicated reentry device was used to allow distal wire entry into the true lumen at the level of the popliteal artery. Despite crushing of the fractured stent with a series of increasingly sized standard balloons, a significant recoil remainded in the area of the crushed stent. To secure patency of the femoro-popliteal artery we therefore decided to implant the novel self-expanding interwoven nitinol stent (Supera Veritas (TM), IDEV), whose unique feature is an exceptional high radial strength. Patient presented asymptomatic without any impairment of his walking capacity at three month follow up and duplex ultrasound confirmed patency of the stent. Subintimal recanalizations can be complicated by previously implanted stents, in particular in the presence of stent fracture, where intraluminal wire passage often can not be achieved. Considering the high radial strength and fracture resistance, interwoven nitinol stents represent a good treatment option in those challenging cases and they can be used to crush standard nitinol and ballonexpandable stents.

Multimodality Imaging of Lower Extremity Peripheral Arterial Disease

Patients with symptomatic peripheral arterial disease (PAD) affecting the lower extremities are initially evaluated with an ankle-brachial index (ABI) and segmental pressure measurements. An ABI 50% stenosis) with a sensitivity and specificity of 79% and 96%, respectively.1 An ABI between 0.90 and 1.0 is considered borderline. The localization of the stenosis can be inferred by an abnormal decrease (>20 mm Hg) in segmental lower extremity pressures. In the presence of calcified atherosclerosis, arteries may become stiff and noncompressible, which results in a falsely elevated ABI (often >1.3). For patients with suspected PAD and a normal ABI at rest, it is valuable to obtain postexercise ABI measurements, which if <0.85 are consistent with PAD and is an independent predictor of mortality.2 Imaging is then needed to confirm the location and degree of stenosis before revascularization or if the diagnosis of PAD is uncertain. Characterization of PAD can be performed with noninvasive angiography using computed tomography (CTA) or magnetic resonance angiography (MRA), as well as with duplex ultrasonography (US), depending on patient specific characteristics (Table 1). Advances in both CTA and MRA provide clinicians with the opportunity to obtain a high resolution, 3-dimensional (3-D) road map of the peripheral arterial tree in patients, particularly when planning revascularization strategies. Invasive digital subtraction angiography (DSA) has been the accepted standard for evaluation of lower extremity atherosclerosis. Although DSA is a robust technique for diagnosing significant arterial stenosis or obstruction, it provides a 2-D view of the vessels, which may underestimate the degree of stenosis for tortuous vessels.3 Furthermore, there are inherent risks with arterial access, ionizing radiation, and the use of iodinated contrast media (CM).4 View this table: Table 1. Comparison Between CTA, MRA, and Duplex US for Diagnosis of PAD This review aims to deliver a comprehensive, yet concise …

Retrograde orbital atherectomy in an occluded superficial femoral artery

Superficial femoral artery (SFA) is commonly diseased in patients with symptomatic peripheral arterial disease. Endovascular treatments have been more effectively used for SFA occlusions with new techniques and devices. Retrograde popliteal access has been used as an alternative to increase the success rate of percutaneous transluminal angioplasty (PTA) of SFA after a failed antegrade attempt. Although orbital atherectomy (OA) has been used effectively to treat SFA occlusions, there are no reports of use of OA by retrograde popliteal approach.

Micro-lightguide spectrophotometry for tissue perfusion in ischemic limbs

To validate micro-lightguide spectrophotometry (O2C) in patients with lower limb ischemia and to compare results with those obtained from toe blood pressure. We prospectively examined 59 patients, 24 of whom complained of claudication, 31 had critical ischemia, and four were asymptomatic. Diabetes was present in 19 (32%) patients. Saturation (SO(2)) and flow measured with O2C were determined with the limb in the horizontal position followed by a 55-cm elevation. Toe pressures were determined in the horizontal position only. In addition, 13 patients were examined before and, on average, 3 days after revascularization. Median SO(2) was 62% (25%-75% percentile: 37%-75%) with the limb in the horizontal position and 16% (3%-41%) with the limb elevated. Comparing the individual toe pressures with SO(2) values measured in the horizontal position and elevated position revealed a significant correlation (r(s) = 0.40; P < .01 and r(s) = 0.56; P < .01, respectively). A low SO(2) (ie, <40% in the horizontal position and <20% in the elevated position) was highly predictive of a toe pressure of 40 mm Hg or less. In the horizontal position, the positive predictive value was 100%, whereas the negative predictive value was 47%. The similar figures in the elevated position were a positive predictive value of 97% and a negative predictive value of 68%. Postoperatively, SO(2) increased significantly from 27% (P25%-75%: 11%-75%) to 79% (68%-87%) in the horizontal position (P = .008) and from 14% (P25%-75%: 2%-39%) to 55% (30%-73%) in the elevated position (P = .011), respectively. Looking at the individual 13 cases in which revascularization was performed, three patients had a partial reconstruction (ie, superficial femoral artery occlusion distal to a central reconstruction or reconstruction to a popliteal blind segment). These patients had significantly lower postoperative SO(2) as well as toe pressure compared with the 10 patients with unobstructed flow to the foot. O2C was easy to use, fast, and painless. The most useful finding was the high predictive value of a low saturation and the rise in O2C values after successful revascularization.

Modification of the Viabahn Padova Sutureless Technique for Challenging Anastomosis Between a Prosthetic Graft and a Circumferentially Calcified Target Artery

To describe modification of the Viabahn Padova Sutureless (ViPS) technique for challenging anastomosis between a prosthetic graft and a circumferentially calcified target artery. The technique is demonstrated in a 75-year-old man with complete superficial femoral artery (SFA) occlusion and reconstitution of a circumferentially calcified above-knee popliteal artery. A 7-mm Viabahn endoprosthesis with its constraining string was withdrawn from its delivery system; the string at the proximal edge of the stent was gently cut with a scalpel, causing the proximal part of the stent to deploy, while the undeployed distal tip with its smooth profile retained its commercial orientation. The proximal end was subsequently sutured to a 7-mm polytetrafluoroethylene (PTFE) graft. After surgical exposure, the popliteal artery was transected, and the undeployed distal portion of the Viabahn was inserted into the distal segment, supported by a stiff guidewire. By pulling the constraining string, the stent was deployed in a "non-reversed" fashion and subsequently dilated to achieve optimal apposition. Finally, the proximal end of the PTFE graft was tunneled under the sartorius muscle and sutured to the common femoral artery. This modification to the ViPS technique using a "non-reversed" method of Viabahn stent preparation allows a safer and more accurate deployment of the endoprosthesis in the calcified target artery.

Aneurysm formation in bovine mesenteric vein grafts after infrainguinal reconstructions

The use of autologous vein graft in infrainguinal arterial bypass grafting (IABG) is the gold standard. However, expanded polytetrafluoroethylene (ePTFE)/heterografts can be also used in cases where the use of autologous vein graft is inappropriate. Biological vascular grafts have been used for many years in the treatment of peripheral arterial diseases. In this report, we present a 62-year-old male who was admitted to our clinic with the symptoms of left lower leg ischemia and diagnosed with left superficial femoral artery occlusion. The patient who did not have an appropriate autologous vein graft underwent femoropopliteal bypass grafting (FPBG) surgery via bovine mesenteric vein graft. At eight months, the patient revisited our clinic with the complaint of a pulsatile mass on the grafting site of the left leg. Aneurysmal dilatation of graft was detected in the patient and aneurysmatic bovine mesenteric vein graft was replaced by ePTFE graft. The patient was discharged on day 8 following uneventful surgery.

Abstract 275: Angioscore Balloon in the Treatment of Collagen Plug Occlusion and Acute Limb Ischemia: Case Report

BACKGROUND: Complications of the vascular access-site (VAS) are not uncommon. With the evolution of hemostatic techniques used in the access site closure, in the last two decades, the rate of VAS related complications has significantly reduced from 6% to 2%. However, they still remain to be an important cause of morbidity following catheterization procedures. The most common complications encountered with closure of VAS are hematoma formation, arterio-venous fistula, dissection, pseudo -aneurysm and limb ischemia. According to two meta-analyses, the incidences of these complications were very low. The incidence of collagen plug from an Angioseal(™) device causing acute leg ischemia is low and upon occurrence, the use of an Angioscore(™) balloon in successful revascularization has never been reported. CASE PRESENTATION: A 62-year-old male with known severe peripheral artery disease, diabetes mellitus, hypertension and hypercholesterolemia had a successful angioplasty of a 100% chronically occluded right superficial femoral artery (SFA) via the left common femoral artery. An Angioseal (™) closure device was used to achieve hemostasis. The patient was discharged home after an uneventful post procedural course. Two days later, he presented to the ER with a cold and numb left lower extremity. On exam, the left lower extremity had no palpable pulse from below right femoral artery, confirmed by Doppler. The extremity was cold to touch with decreased sensory perception. Patient was found to have critical left lower extremity ischemia. He was emergently taken for a selective left lower extremity angiogram using the right common femoral artery for access. Fragments of the closure device and a collagen plug causing a total occlusion of the left common femoral artery were found. After a pre-dilatation with a 4.0x 40 balloon under prolonged inflations, a lesion reduction from 100 % to 30% with a TIMI 0 to TIMI 3 flow was achieved using an Angioscore (™) 5.0x 40 balloon inflated at 10 atmospheres. Subsequently, using laser 2.0 atherectomy of the left common femoral artery was performed. Flow in the dorsalis pedis artery was confirmed with Doppler. DISCUSSION: The Angio-Seal(™) device has a polylactide and polyglycolide polymer anchor, a collagen plug and a suture contained within a carrier system. Hemostasis is achieved by compressing the arterial puncture site between the anchor and the collagen plug. With newer studies, it appears that the occurrence of critical limb ischemia from collagen plug is under recognized. We therefore, with this case report urge the physicians to be aware of this serious though rare complication of closure devise and also highlight the successful use of Angioscore (™) balloon in the emergent treatment of non-athermatous vascular occlusion causing critical limb ischemia.

Transcollateral Approach for Percutaneous Revascularization of Complex Superficial Femoral Artery and Tibioperoneal Trunk Occlusions

This report describes the use of transcollateral retrograde revascularization in two patients after failed recanalization of the tibioperoneal trunk in one and superficial femoral artery occlusion in the other. Retrograde recanalization was successfully achieved via a distal branch of the profunda femoris artery in the first case and a medial genicular branch in the second. After successful retrograde recanalization, the guide wire was snared in both cases and angioplasty/stent placement was performed in an antegrade fashion.

Recanalization of Femoropopliteal Chronic Total Occlusions Using the ENABLER-P Balloon Catheter System

To evaluate the safety and effectiveness of a new system to facilitate intraluminal advancement of conventional guidewires through chronic total occlusions (CTO) of the superficial femoral artery (SFA) and popliteal artery. The ENABLER-P Balloon Catheter System uses a unique balloon-anchoring mechanism and an automated balloon inflation device for steady, controlled advancement of a standard non-hydrophilic guidewire. The system was evaluated in 37 patients (22 men; mean age 67 years (range 41-87) with femoropopliteal CTOs averaging 86 mm in length (range 10-340). The device was used in a variety of occlusions, including heavily calcified, long, and fibrotic lesions. After successful guidewire recanalization facilitated by the system, occluded arterial segments were treated conventionally with balloon angioplasty, atherectomy, and stents as appropriate. The primary endpoint of successful crossing was achieved in 86% (32/37) of the overall study population. The average activation time for successful crossing was 5.3 minutes (range 0.4-22). Of the 32 cases successfully crossed with the ENABLER-P System, all but 1 was successfully recanalized. One (3%) device-related complication occurred when the wire was advanced into a side branch when treating a 300-mm-long flush ostial SFA occlusion; the resulting perforation was managed with a covered stent without further sequelae. This novel system, which provides enhanced force to a standard guidewire tip for controlled intraluminal advancement, is a promising device for the treatment of peripheral CTOs.

The dangers of damage control orthopedics: a case report of vascular injury after femoral fracture external fixation

BackgroundPlacement of external fixation frames is an expedient and minimally invasive method of achieving bone and joint stability in the setting of severe trauma. Although anatomic safe zones are established for placement of external fixation pins, neurovascular structures may be at risk in the setting of severe trauma.Case reportWe present a case of a 21-year-old female involved in a high speed motorcycle accident who sustained a Type IIIB open segmental femur fracture with significant thigh soft tissue injury. Damage control orthopedic principals were applied and a spanning external fixator placed for provisional femoral stabilization. Intraoperative vascular examination noted absent distal pulses, however an intraoperative angiogram showed arterial flow distal to the trifurcation. Immediately postoperatively the dorsalis pedis pulse was detected using Doppler ultrasound but was then non-detectable over the preceding 12-hours. Femoral artery CT angiogram revealed iatrogenic superficial femoral artery occlusion due to kinking of the artery around an external fixator pin. Although the pin causing occlusion was placed under direct visualization, the degree of soft tissue injury altered the appearance of the local anatomy. The pin was subsequently revised allowing the artery to travel in its anatomic position, restoring perfusion.ConclusionThis case highlights the dangers associated with damage control orthopedics, especially when severe trauma alters normal local anatomy. Careful assessment of external fixator pin placement is crucial to avoiding iatrogenic injury. We recommend a thorough vascular examination pre-operatively and prior to leaving the operating room, which allows any abnormalities to be further evaluated while the patient remains in a controlled environment. When an unrecognized iatrogenic injury occurs, serial postoperative neurovascular examinations allow early recognition and corrective actions.

Results of heparin-bonded ePTFE-covered stents for chronic occlusive superficial femoral artery disease

The purpose of this study was to assess the 1-year patency rates of heparin-bonded covered stents in the treatment of chronic occlusive disease of the superficial femoral artery (SFA). All patients treated with a heparin-bonded endograft between April 2009 and October 2010 for chronic occlusive disease of the SFA were prospectively gathered in a database and retrospectively analyzed. Primary, primary-assisted, and secondary patency rates, assessed by ultrasound scanning, were analyzed at 1-year, as were the complication rates and mortality. A total of 56 limbs were treated with a heparin-bonded covered stent in 53 patients for chronic ischemia Rutherford category 3 (n = 36), 4 (n = 5), 5 (n = 11), and 6 (n = 1). Lesions were classified as TransAtlantic Inter-Society Consensus (TASC)-2-B (n = 9), C (n = 14), and D (n = 33), and the mean treated lesion length was 18.5 ± 7.7 cm. Postoperative complications occurred in 7.5%, including hematoma (n = 1), edema (n = 1), pneumonia (n = 1), and urinary retention (n = 1), and the 30-day mortality rate was 0%. The mean follow-up was 413 ± 208 days. At 1 year, the primary patency was 76%, the primary-assisted patency 82%, and the secondary patency 89%. The limb salvage rate was 100%. Heparin-bonded covered stents seem to provide a valid alternative to surgical treatment of long occlusive lesions in the SFA. Randomized trials and long-term data are required before considering the technique as a new standard of care.

Stent Puncture for Recanalization of Occluded Superficial Femoral Artery Stents

To describe a technique to recanalize occluded superficial femoral artery (SFA) stents without inflow or outflow in patients with proximal SFA obstruction. After a failed attempt to engage an occluded stent through an antegrade femoral approach, a distal retrograde puncture of the proximal part of the stent was performed. After subintimal rendezvous with a catheter advanced from the antegrade access, in-stent angioplasty can be performed to recanalize the stent and SFA. Direct retrograde puncture of an occluded stent may be considered an approach to recanalization in patients with stent occlusion and no inflow or outflow.

Retrograde Recanalization Technique for Use After Failed Antegrade Angioplasty in Chronic Femoral Artery Occlusions

To describe a technique to approach chronic total occlusions (CTOs) of the superficial femoral artery (SFA) after failed antegrade recanalization as an alternative to a conventional transpopliteal approach. A retrospective analysis was undertaken of 50 patients (37 men; mean age 71 years) who underwent retrograde recanalization via a distal SFA access after failed antegrade recanalization of SFA CTOs that were not beyond the adductor canal. Antegrade recanalization failed due to flush SFA occlusion, occluded stents, wire perforation, and re-entry failure. Retrograde SFA access required introduction of a 7- to 15-cm, 21-G needle distal to the occlusion. A 0.018-inch guidewire was inserted through the needle followed by a 4- or 6-F, 10-cm sheath or dedicated support catheter only. All retrograde SFA punctures were performed with the patient in the supine position. Once retrograde passage of the occlusion was successful, oftentimes requiring a "double-balloon" technique to disrupt the dissection membrane with abutting balloons delivered from both access sites, balloon angioplasty and/or stenting could be performed from either direction. Retrograde puncture of the distal SFA was successful in all cases. Retrograde recanalization involved insertion of a 6-F sheath in 3 (6%) cases, a 4-F sheath in 32 (64%), and a sheathless approach in 15 (30%). The "double-balloon" technique was necessary to achieve guidewire passage in 12 cases. Recanalization was successful in 48 (96%) cases. Hemostasis time at the distal puncture site was 9.2 minutes (range 3-30). Perioperative complications included 4 pseudoaneurysms (2 groins, 2 distal), 1 peripheral embolization, and 1 small arteriovenous fistula at the distal puncture site. For failure of antegrade recanalization of SFA occlusions, the retrograde SFA puncture distal to the adductor canal with the patient remaining supine is a safe and successful technique that represents a convenient alternative to the conventional transpopliteal approach.

Subintimal Angioplasty Track of the Superficial Femoral Artery

Since it was first described in 1990, subintimal angioplasty (SIA) has proven to be a valuable alternative for bypass surgery in patients with atheroocclusive disease of the superficial femoral artery (SFA).1 In this minimally invasive technique, a guidewire is intentionally placed between the intima and the media to create a new track along the vessel wall, bypassing the atherosclerotic occlusion.2 However, to our knowledge, the exact route of this subintimal track has never been confirmed with histopathology. There have been debates about the exact route of the guidewire during this procedure. Bolia et al2 were the first to report on this technique and emphasized that during subintimal passage, the guidewire does not pass the medial layer. On the other hand, Reekers et al3 observed that large, extensive, medial calcifications often result in the inability to perform this technique and concluded that the passage through the medial layer is necessary. Reekers et al, therefore, preferred to call this technique percutaneous intentional extraluminal revascularization. In this case report, we present a patient from whom an endarterectomy specimen of an occluded SFA was obtained 2 months after an SIA procedure, which gave the unique opportunity to study the exact route of the subintimal track using histopathology. ### Case A …

Retrograde popliteal access as bail‐out strategy for challenging occlusions of the superficial femoral artery: A multicenter registry

The concomitant use of femoral and popliteal accesses has been recommended for challenging superficial femoral artery (SFA) occlusions, but no comprehensive comparison of this approach to a strategy of femoral access only is available. We thus aimed to appraise the risk-benefit balance of retrograde popliteal access as bail-out strategy for SFA occlusions. Consecutive patients with symptomatic SFA occlusion and undergoing percutaneous revascularization were enrolled. We distinguished patients in whom retrograde popliteal access was required as bail-out strategy versus those not requiring such access. The primary end-point was procedural success. A total of 130 patients (152 limbs) were included, with 23 patients (25 limbs) requiring retrograde popliteal access. Occlusion length was 20.6 ± 8.8 cm in those requiring popliteal access versus 18.5 ± 8.5 cm in those without popliteal access, with TASC C/D lesions in 23 (92%) versus 106 (83%). Procedural success was achieved in 92 out of 107 patients (86.0%) treated with a standard approach and 22 out of 23 patients (95.7%) treated with retrograde popliteal access (total 114 out of 130 [87.7%]) and 112 out of 127 limbs (88.2%) and 24 out of 25 limbs (96.0%), respectively (total 136 out of 152 [89.5%]). No significant increase in early or long-term adverse events was associated with retrograde popliteal access. Whenever standard access sites do not enable successful recanalization of SFA occlusions, retrograde popliteal access can be safely and effectively envisioned as bail-out strategy.

The Effectiveness of Skin Perfusion Pressure Measurements during Endovascular Therapy in Determining the Endpoint in Critical Limb Ischemia

A 78-year-old man had right foot ulceration. The skin perfusion pressure (SPP) at the dorsum was 12 mmHg. Angiography revealed right iliac artery occlusion and diffuse stenosis of right superficial femoral artery. After stenting of the iliac arteries, the SPP was still 23 mmHg. Hence, we also inserted stents in the right superficial femoral artery. The anterior tibial artery remained stenosed, and the posterior tibial and fibular arteries were occluded. However, as the SPP had increased to 46 mmHg the treatment was discontinued. The ulcers improved. Measurement of SPP during a procedure may be useful in determining the treatment endpoint.

Lift the quilt in case of atrial fibrillation and disc prolapse

BackgroundPeripheral embolism to the lower extremities may mimic disc prolapse with severe consequences.Case reportA 71-year-old male with a history of chronic alcoholism developed low back pain radiating to both lower extremities in a nonradicular distribution and bilateral dysesthesias of the distal lower legs after lifting a heavy weight. Given that magnetic resonance imaging (MRI) of the lumbar spine showed disc herniation in L3/4 and L4/5, he was scheduled for laminectomy but was unable to undergo surgery due to thrombocytopenia. After transfer to another hospital, persistence of symptoms and signs, absent pulses on the distal lower legs, and rhabdomyolysis with temporary renal insufficiency, peripheral embolism with compartment syndrome was suspected. Magnetic resonance angiography revealed occlusion of the right superficial femoral artery and long high-grade stenosis of the left superficial and profound femoral arteries and distal arteries. He successfully underwent embolectomy and fasciotomy.ConclusionsIf lumbar pain is not radicular, peripheral pulses are minimally palpable, and distal limbs are cold and show livid decolorization, peripheral embolism is much more likely than disc herniation, particularly if the patient’s history is positive for atrial fibrillation. MRI of the lumbar spine must be interpreted in conjunction with clinical presentation.

Successful Extra-Anatomical Recanalization of Occluded Superficial Femoral Arteries Using the Outback Device—A Report of 2 Cases

We report 2 cases where the Outback catheter facilitated extra-anatomical bypass after vessel perforation during attempted subintimal vessel dissection. Attempted subintimal angioplasty of the superficial femoral artery (SFA) resulted in vessel perforation in 2 patients with chronic SFA occlusion and limb ischemia. Due to the lack of other endovascular or surgical options, the Outback catheter was used to reenter the patent lumen distal to the perforation. A stent graft was then deployed from proximal to the perforation to beyond the reentry point with successful outcomes. Although the reentry devices are typically used to enter the lumen from the subintimal plane, this novel technique involves using the Outback catheter to enter from the extravascular compartment and facilitate bypass of the SFA occlusion via an extra-anatomical route. This novel technique can be used to restore in-line blood flow when attempted endovascular revascularization failed due to vessel perforation.

TCT-601: Midterm Outcomes of S.M.A.R.T. Self-Expanding Nitinol Stent Implantation for Chronic Total Occlusion of Superficial Femoral Artery

TCT-601: Midterm Outcomes of S.M.A.R.T. Self-Expanding Nitinol Stent Implantation for Chronic Total Occlusion of Superficial Femoral Artery