CLI Case Study Presentation Jos C. van den Berg, MD PhD Ospedale Regionale di Lugano, sede Civico, Lugano University of Bern Switzerland
Disclosures • No disclosures related to this presentation Brand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.
Case presentation • 89 year-old man • Resection axillary melanoma 2011 • Atrial fibrillation (anticoagulation Lixiane) • Non-healing post-traumatic pre-tibial ulcer (7 weeks) • Prior stenting popliteal artery April 2018 (St. Elsewhere)
Clinical presentation
Plethysmography
Duplex • Occlusion stent popliteal artery • Status BTK?
Therapeutic plan • Antegrade puncture (US guidance) left CFA • Diagnostic angiography • Recanalization stent • PTA and DEB in-stent
Ultrasound guidance
Ultrasound guidance
Diagnostic angiography
Diagnostic angiography
Diagnostic angiography • Occlusion popliteal artery – In-stent – P2 and P3 segment • Occlusion trifurcation – Good quality posterior tibial artery – Stenotic peroneal artery – Occluded anterior tibial artery • Next step? Target vessel?
Procedure Intraluminal/subintimal recanalization Preferential course guidewire towards anterior tibial artery (dead end street)
Procedure Preferential course guidewire towards peroneal artery
Procedure Guidewire towards peroneal artery, remaining subintimal
Procedure Selective angiography demonstrates collateral towards posterior tibial artery Cannulation with Carnelian Support14
Procedure Carnelian Support 14 with 0.014” Terumo GT Gold, afterwards exchange for 0.014” Terumo Advantage
Procedure Advancement from distal to proximal
Procedure Re-entry into distal tibioperoneal trunk and popliteal artery
Procedure Withdrawal Carnelian Support 14, leaving wire in place and antegrade recanalization with 0.018” CXI using 0.014” guidewire as ‘track’
Procedure
Control angiography
Clinical course • Same day discharge (day-hospital) • Wound rapidly improving (@ 3 weeks FU)
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