A CASE OF STENT THROMBOSIS CLAUDIA SERRANO, MD CLINICAL ASSISTANT - PowerPoint PPT Presentation

A CASE OF STENT THROMBOSIS CLAUDIA SERRANO, MD CLINICAL ASSISTANT PROFESSOR NYU LANGONE

Disclosures: ▪ I have nothing to disclose.

• 63 yo male • Hypertension, and dyslipidemia • Two recent long trips greater than 10 hours • Presented with 1 week of right lower extremity paresthesias and pain

• Venous duplex ultrasound • Patent veins • Mass in the popliteal fossa • MRI/MRA of the knee • 4.5 cm popliteal aneurysm with occlusion of 8 cm segment of popliteal artery

Peripheral angiography: Total occlusion of popliteal artery IVUS: 8.8 x 9.5 mm luminal diameter

Revascularization: Pre-dilatation balloons: 4 x 150 mm 6 x 150 mm Covered stent: Viabahn 10 x 150 mm Post-dilatation balloons: 8 x 80 mm 9 x 40 mm 10 x 40 mm

• Aspirin 81 mg daily • Clopidogrel 75 mg daily • Apixaban 5 mg BID

3 weeks later Patient experience recurrence of rest leg pain on the right and rubor when standing Arterial ultrasound: Stent thrombosis

Peripheral angiography: Left radial access Viabahn stent occluded Intervention: Local lytic therapy: Perfusion catheter tPA 20 mg bolus then 2 mg/h infusion x 6 hours, then 1.2 mg/h IV Anticoagulation: Heparin 500 U/h

• Follow up peripheral angiography: • Continue tPA to complete 24 hours infusion • Ticagrelor 180 mg loading dose, then 90 mg BID

• Aspirin held • Clopidogrel held • Apixaban held

• Follow up angiography: • tPA infusion completed x 48 hours • IV heparin bridge to full anticoagulation with warfarin • Continue with Ticagrelor 90 mg BID

Patient returns 2 days later with acute onset right leg pain consistent with acute limb ischemia

• Peroneal artery: Spider filter wire • Popliteal and TP trunk: tPA infusion: 15 mg • Popliteal: Thrombectomy with Jet Stream • Popliteal and distal PT: Thrombectomy with 4 mm Angiojet

• Peroneal and TP trunk: Dilatation balloon: 3 x 210 mm • Distal PT: 4 mm Angiojet and 5 mg tPA infused followed by 4x 80 mm dilatation • Popliteal: 1 mg/h tPA local infusion by perfusion catheter • Heparin infusion 500 U/h

Follow up angiography: Stop tPA Ticagrelor 90 mg BID Aspirin 81 mg daily Rivaroxaban 15 mg daily

THE E END !!!