Endovascular Intervention For Nearly Occlusion Left

Popliteal Artery in
Tangerang Hospital
Novrizal Saiful Basri, Kemas Dahlan, Ismon Kusasi
Vascular and Endovascular Division, Department of Surgery, Ciptomangunkusumo National
Hospital
Faculty of Medicine University of Indonesia

Abstract
Introduction
Peripheral arterial disease (PAD) is a leading cause of death worldwide. The
important risk factors are smoking, diabetes mellitus, hypertension, and
hypercholesterolemia. Advances in the diagnosis and successful treatment of
PAD have occurred rapidly, and now include broader use of noninvasive
duplex ultrasonography (US) and minimally invasive endovascular
techniques. This report describes a case of peripheral artery disease that had
been done balloon angioplasty as the choice of treatment rather than open
surgery.
Case Report
We report a 52-years-old man presented to the outpatient clinic with a chief
complaint of a wound at his right foot for 2 months. The complaint started 2
months ago when his foot was blackened and being amputated then. Until
now the patient is still in the wound care. Patient also complaint pain on his
feet especially after he walked. This patient has a history of amputation 8
years ago on his 4th and 5th phalanx. There is no history of diabetes mellitus
and hypertension. The physical examination showed positive one on bilateral
dorsalis pedis and posterior tibial. The ABI was 0.8/0.8. An arteriography was
performed with an access from the left femoral artery and the result was 8,5
cm length near total occlusion of the popliteal artery. Then a balloon
angioplasty was performed on the right popliteal artery occlusion and an
angiography was performed, the occluded part was opened.
Conclussion
Peripheral arterial disease (PAD) manifestation include some type of pain
range from no symptoms to intermittent claudication to critical limb ischemia
(CLI). History or clinical risk factors are important in making diagnosis.
Measurement of the ankle-brachial index (ABI) is the primary method for

establishing the diagnosis of PAD. The role of endovascular intervention in

the treatment of limb-threatening ischemia is also expanding, and its
promise of limb salvage and symptom relief with reduced morbidity and
mortality makes percutaneous transluminal angioplasty/stenting an
attractive alternative to surgery and, as most endovascular interventions are
performed on an outpatient basis, hospital costs are cut considerably.

Introduction
Peripheral arterial disease (PAD) is a leading cause of death worldwide.
The important risk factors are smoking, diabetes mellitus, hypertension, and
hypercholesterolemia. Advances in the diagnosis and successful treatment of
PAD have occurred rapidly, and now include broader use of noninvasive
duplex ultrasonography (US) and minimally invasive endovascular
techniques. 1-3 This report describes a case of peripheral artery disease that
had been done balloon angioplasty as the choice of treatment rather than
open surgery.

Case Presentation
Male, 52 years old presented to the outpatient clinic with a chief complaint of
a wound at his right foot for 2 months. The complaint started 2 months ago
when his foot was blackened and being amputated then. Until now the
patient is still in the wound care. Patient also complaint pain on his feet
especially after he walked. This patient has a history of amputation 8 years
ago on his 4th and 5th phalanx. There is no history of diabetes mellitus and
hypertension. The physical examination showed positive one on bilateral
dorsalis pedis and posterior tibial. The ABI was 0.8/0.8

Figure 1 and 2. Clinical Pictures.

An arteriography was performed with an access from the left femoral artery
and the result was 8,5 cm length near total occlusion of the popliteal artery.

Figure 3. Before balloon angioplasty arteriography.

Then a balloon angioplasty was performed on the right popliteal artery

occlusion and an angiography was performed, the occluded part was opened.

Figure 4. Balloon angioplasty.

Figure 5. After Balloon angioplasty arteriography.

After the balloon angioplasty, patient was given :

-

Heparin bolus 5000 IU followed by heparin 20000 drip IU / 24 hours

Clopidogrel 1x75 mg
Cilostazol 2x50 mg
Xartel 1x20 mg

First day post operative laboratorium :

PT/apTT 20.6 (14.4)/61.2(33.1)
Second day post operative laboratorium
2/7/15 12.9(14.5)/36.7(36.4)
Patient was discharged at the third day.

Discussion
Chronic lower extremity ischemia, also known as peripheral arterial
disease (PAD), is the most common cause of loss of normal walking ability
seen by the vascular specialist. The manifestations of chronic lower
extremity ischemia usually include some type of pain and are produced by
varying degrees of muscle ischemia; they range from no symptoms to
intermittent claudication to critical limb ischemia (CLI). History, physical
exam, and noninvasive tests are nearly always sufficient to make the
diagnosis of peripheral arterial disease (PAD). 1-4 In present case, the
patient complain of unhealing wound with intermitten claudication.
Clinical risk factors based on literature and journals are cardiac history,
cerebrovascular history, current smoking, diabetes mellitus, dyslipidemia,
hypertension, prior percutaneous coronary intervention, prior coronary artery
bypass graft, and prior myocardial infarction. Measurement of the anklebrachial index (ABI) is the primary method for establishing the diagnosis of
PAD. An ABI of <0.90 has been demonstrated to have high sensitivity and
specificity for the identification of PAD compared with the gold standard of
invasive arteriography. 5-7 In this case, the patient only has history of
smoking without other clinical risk factors. The ABI of both limbs were
0.8/0.8.
Surgical and endovascular therapy (EVT) are likely to be similar in
efficacy overall, although the quality of supporting evidence comparing the
two is poor and the likelihood of durable clinical success different. The role of
endovascular intervention in the treatment of limb-threatening ischemia is
also expanding and its promise of limb salvage and symptom relief with
reduced morbidity and mortality makes percutaneous transluminal
angioplasty/stenting an attractive alternative to surgery. Catheter
arteriography represents the gold standard due to superior image resolution
and the unique ability of being able to perform a diagnostic study and EVT at
the same time. Arguably, as long as endovascular intervention does not
negatively affect a patients option to have an open surgery in the event of
restenosis or reocclusion, endovascular intervention can be attempted for
even complex lesions.4,7,8 In this case, arteriography and balloon
angioplasty were choose as the main diagnostic study and treatment
because of the less morbidity and more effective.
In conclusion, peripheral arterial disease (PAD) manifestation include
some type of pain range from no symptoms to intermittent claudication to

critical limb ischemia (CLI). History or clinical risk factors are important in
making diagnosis. Measurement of the ankle-brachial index (ABI) is the
primary method for establishing the diagnosis of PAD. The role of
endovascular intervention in the treatment of limb-threatening ischemia is
also expanding, and its promise of limb salvage and symptom relief with
reduced morbidity and mortality makes percutaneous transluminal
angioplasty/stenting an attractive alternative to surgery and, as most
endovascular interventions are performed on an outpatient basis, hospital
costs are cut considerably.
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