NO ENTRY SITE

Resident(s): Alexandria S. Jo, MD

Attending(s): Narasimham L Dasika, MD
Program/Dept(s): University of Michigan Department of Interventional Radiology

DISCLOSURES
No conflict of interest and relationships to disclose for this presentation
I may be discussing products that are investigational or not labeled by FDA for such
use under discussion

HPI
69 year old male with well known peripheral arterial disease (PAD)
and previous episodes of critical limb ischemia (CLI).
Now presenting with 3 week history of right foot pain at rest.
Sleeping in a chair because his right foot hurts severely while in bed.
He gets relief by standing or hanging the right leg from edge of the
bed.
Currently can walk only 20 feet before he gets disabling right
claudication.
Also with rapidly worsening right heel ulcer and increased right leg
swelling.

HPI
His symptoms significantly worsened since an unsuccessful attempt at
lysis of ilio-profunda graft thrombosis 2 months back.
He was offered right above knee amputation at 2 different outside
facilities.
He also has long standing left lower extremity symptoms. He feared
that right leg amputation would ultimately result in decreased activity
and lead to eventual amputation of the other leg.
Thus, he came to our PAD clinic for a 3rd minimally invasive option
before resorting to amputation of his right leg.

PAST MEDICAL HISTORY

Past medical history: Hypertension (HTN), hyperlipidemia (HLD),
coronary artery disease (CAD) status post stenting in 2004,
asthma, obesity
Social history: 50 pack per year smoking, 3-4 beers a day, retired
automotive plant supervisor
Family history: HTN, CAD, HLD, PAD
Home medications: Aspirin, Clopidogrel, Warfarin, Bisoprolol,
Hydrochlorothiazide, Rosuvastatin

PAST SURGICAL HISTORY: EXTENSIVE PRIOR

ENDOVASCULAR AND SURGICAL PROCEDURES
April 2, 2001: Percutaneous translumintal angioplasty of his SFA with S.M.A.R.T. stent placement of the right superficial femoral artery (SFA)
April 17, 2001: Left common femoral endarterectomy and PTA of his left SFA.
May 6, 2004. A right iliofemoral endarterectomy with a Fem-PT vein graft occluded post operatively due to in-flow disease in a week.
July 15, 2004: PTA and a stent in his right external iliac artery.
July 27, 2004: Right common femoral artery to posterior tibial sequential basilic vein bypass.
December 27, 2004: A drug-eluting stent in his distal bypass graft at the mid tibial level.
April 26, 2005: A drug-eluting stent in his proximal bypass graft.
July 26, 2005. A sirolimus stent in his upper leg graft.
June 12, 2007: A right ileofemoral to profunda and SFA as well as an SFA endarterectomy.
October 9, 2008: A right common femoral artery profundoplasty and endarterectomy.
June 4, 2010: Lysis of his right iliac-profunda bypass and laser atherectomy of his right common femoral artery and a proximal graft
December 11, 2012: Right SFA intrastent stenosis with thrombus in the graft and recurrence of extensive atheromatous plaque in the right
popliteal and tibial arteries. Post arthrectomy, thrombectomy and angioplasty demonstrated three-vessel outflow with no intraluminal
thrombus with significant improvement in the Doppler signals in the right foot.
October 15, 2013: Angioplasty of the right popliteal SFA.

PHYSICAL EXAMINATION
Toes are hypersensitive to touch
Bilateral femoral and pedal pulses are not palpable

Right leg: Dependent rubor, 1+ pitting edema

Right heel: Shallow 1cm ulcer
Right foot is cool with very poor capillary refill
Left foot: Poor capillary refill, (better than right) with no ulcers
Bilateral pedal doppler signals are monophasic

PREVIOUS IMAGING STUDIES:

CTA OF THE ABDOMEN, PELVIS AND LOWER EXTREMITY

Extensive calcified atherosclerotic plaque throughout the aorta and its branch vessels.
There is a endoluminal external iliac artery stent extending from common iliac bifurcation to 4 cm proximal to the groin.
The stent is proximally partially collapsed and distally there is mild to moderate luminal narrowing.

PREVIOUS IMAGING STUDIES:

CTA OF THE ABDOMEN, PELVIS AND LOWER EXTREMITY
Evaluation of the right lower
extremity
Common femoral: Occluded grafts from
the CFA to the proximal SFA and to
branch of the profunda.
Superficial femoral: Almost completely
occluded throughout
Deep femoral: Partially occluded
proximally with extensive collaterals
down the thigh and into the proximal
leg.
Popliteal: occluded
Tibioperoneal trunk: heavily calcified
and possibly occluded.
Anterior tibial: Patent
Posterior tibial: Patent
Peroneal: Patent with dense
calcification at origin that may cause
stenosis.

SEGMENTAL PRESSURES AND ABI/TBI

RIGHT

LEFT

No signal

BRACHIAL

126 (0.74)

No signal

PROXIMAL
THIGH

80 (0.47)

No signal

HIGH CALF

64(0.37)

45 (0.26)

ANKLE PT

46 (0.27)

34 (0.20)

ANKLE DP

40 (0.23)

9 (0.05)

FIRST TOE

22 (0.13)

Results:
R ABI of 0.26 (monophasic)
R TBI of 0.05 (pressure of 9)
L ABI of 0.27 (monophasic)
L TBI of 0.13 (pressure of 22)
R right iliac to profunda bypass graft is
occluded.

DIAGNOSIS AND STAGING

Rutherford 2b Rest pain
Clinical Category 5 minor tissue loss
(Ankle pressure<40)

Fontaine Stage III (rest pain)

TASC D
ABI based (Critical multi segmental)

Findings are diagnostic of CRITICAL LIMB ISCHEMIA

ANGIOGRAM: PELVIS AND GROIN

ANGIOGRAM: PELVIS AND GROIN

EXTERNAL ILIAC: There is a endoluminal external iliac artery stent which extends from the common iliac bifurcation to approximately 4 cm
proximal to the groin. The majority of the stent is patent, though proximally it appears partially collapsed. Distal to stent there is mild to moderate
luminal narrowing.
COMMON FEMORAL: Occluded. There are occluded grafts from the CFA to the proximal SFA and to branch of the profunda femoris.

ANGIOGRAM: THIGH AND PROXIMAL LEG

SUPERFICIAL FEMORAL : Almost completely occluded throughout, with

only a few short segments demonstrating collateral flow.
DEEP FEMORAL : Partially occluded proximally with reconstituted flow with
extensive collaterals extend down the thigh and into the proximal leg.

POPLITEAL : Occluded
ANTERIOR TIBIAL : Patent just distal to its origin
POSTERIOR TIBIAL : Patent
PERONEAL : Patent, with dense calcification near its origin, likely causing some stenosis.

ANGIOGRAM: DISTAL LEG AND FOOT AFTER VASODILATION

Deformed posterior
tibial artery due to
previous stenting

Intact posterior
tibial artery

Intact dorsalis
pedis artery

Deformed posterior
tibial artery due to
previous stenting

Intact posterior
tibial artery

CHALLENGING ANATOMY
Extremely long (>55 cm) chronic total occlusion.
Occlusion of the distal right external iliac, CFA, SFA and proximal profunda.
Small right internal iliac artery with reconstituting discontinuous profunda.
Occluded prior right SFA stents.
Excessive diffuse calcification and hostile groin from previous interventions.
Occluded right popliteal artery.
Ostial occlusion of the right tibial arteries, But patent anterior tibial, distal
posterior tibial and peroneal arteries.
Deformed posterior tibial artery from previous stent placement.
In addition, the patient had advanced contralateral left lower extremity disease.

DECISION MAKING
Now what?
The patient had come to our institution as a last resort before considering above the knee amputation
of his right leg.
With his bilateral disease, amputation of the right leg will inevitably lead to decreased activity levels
which will most likely lead to disease progress in his left lower extremity.
With his extensive disease, conservative medical treatment alone would not control his symptoms or
stop/delay the progression of the disease process.
Vascular surgical or surgical/endovascular intervention was not feasible due the extent of vessel
involvement and hostile surgical field due to multiple previous interventions.

ENCOURAGING FINDINGS
Despite the extensive
above knee vessel disease,
the patient still had:
Patent distal 2/3 of right
anterior tibial artery with
patent dorsalis pedis
Patent distal of right
posterior tibial artery
with preserved continuity
to the plantar arch
Diseased but segmental
patency of the right
peroneal artery

Deformed posterior
tibial artery due to
previous stenting

Intact posterior
tibial artery

Intact dorsalis
pedis artery

Intact posterior
tibial artery

FINAL CLINICAL DECISION

With these findings, we decided to perform a stepwise, multilevel, sharp,
subintimal recanalization through subintimal arterial flossing
with antegrade-retrograde intervention (SAFARI) with artherectomy
and stenting.

INTERVENTION: ACCESS #1
ACCESS THROUGH THE LEFT COMMON FEMORAL ARTERY
Initial access through the left common femoral artery.
Placement of 5 french arterial sheath.
Advancement of glidewire into the right external iliac

and upsizing of the sheath to a 6-french Ansell

sheath
5 Fr VERT catheter advanced over guidewire
through arterial sheath to the level of obstruction
at the right distal external iliac artery
Recanalization of the right common femoral artery
from the left femoral arterial access was attempted
but was unsuccessful.

INTERVENTION: ACCESS #2
ACCESS THROUGH THE RIGHT SFA STENT
With the calcification as guidance,
right mid SFA was accessed and a
Glidewire was advanced retrograde
to the right groin.
Sharp recanalization of the occluded
right common femoral and distal
external iliac artery was performed
with the stiff end of a Glidewire.
This wire was snared from the left
common femoral access site and the
recanalized common femoral artery
and the proximal SFA was balloon
dilated.
Sequential subintimal recanalization
with angioplasty of the right distal
external iliac, common femoral and
proximal superficial femoral artery
was performed.
Most of the recanalized segment of
the right common femoral and the
right superficial femoral artery was
performed subintimal.

INTERVENTION: ACCESS #3
PEDAL (AT) ACCESS

We then attempted to perform subintimal recanalization of the distal SFA and the popliteal artery.
A pre-existing occluded Nitinol stent in the distal SFA extensive heavy calcified arteries made this procedure extremely difficult.
With the help of multiple quick cross catheters and multiple guidewires, we were finally able to enter the occluded Nitinol stent and through the stent reached to the level of
intercondylar fossa. However we could not re-enter the true lumen of the popliteal artery.
We then decided to recanalize the leg arteries through a pedal access. The right anterior tibial artery was accessed at the level of the ankle.
A 4-French stiff micropuncture sheath was advanced into the distal anterior tibial artery.

INTERVENTION: ACCCESS #4
ACCESS THROUGH PROXIMAL AT
DIRECTLY FACING THE BEND
Retrograde recanalization of proximal AT
and the tibioperoneal trunk was
performed with a combination of 0.018
compatible quick cross catheter, V18 wire,
and multiple 0.018 glide wires. Once again
we could not enter into the popliteal
artery at the knee joint.

We then advanced a 2.5 mm x 15cm sleek

mono rail balloon into the distal
tibioperoneal trunk and balloon dilated the
recanalized tibioperoneal trunk. Through
the inflated balloon, popliteal artery was
bluntly dissected.
The balloon catheter was taken out, and a
4 Fr sheath was advanced into the distal
right AT. Through this sheath a 64 cm 4 Fr
angled glide catheter was advanced into
the popliteal artery.
Blunt dissection up to the level of the
adductor canal from the proximal popliteal
artery was performed using a 0.035 stiff
Glidewire.

RETROGRADE 2 LEVEL SAFARI VIA 4TH ACCESS

A 300 cm long PT
graphics wire was
advanced through the
right AT access into the
popliteal artery.
This wire was snared
from the contralateral
access to obtain a
through and through
access.
Over the through and
through wire, the distal
popliteal artery and the
tibioperoneal trunk
were balloon dilated
with 4mm savvy
balloons.
Multiple balloons
ruptured due to
extensive calcification.

HIGH PRESSURE POBA

From the contralateral access, through the a 6-French Ansell
sheath, a 0.035 quick cross catheter was advanced into the
recanalized the subintimal channel of the right SFA. The quick
cross catheter was then exchanged for an Amplatz wire.
The heavily calcified recanalized subintimal channel was
repeatedly dilated with Fox balloons, 4 to 6 mm in diameter.
Several balloons ruptured due to spikes of calcium protruding
into the subintimal channel.
A communication was created with sharp dissection between
the subintimal channel of the SFA and the retrograde access
from the popliteal artery. Predilatation of the popliteal artery
and the entire subintimal channel was performed with Fox and
OPTA balloons.
Segment of the new channel created was deliberately passed
through the center of the previously placed and occluded right
SFA Nitinol stent. Further dilation of the entire proximal
popliteal artery and the subintimal channel of flow common
femoral and superficial femoral arteries was dilated to 6 mm
with Dorado balloons.

HIGH PRESSURE POBA FAILED TO RESTORE FLOW

Angiogram of this extensive
recanalization revealed no flow
through the recanalized segments
due to collapse of the subintimal
channel from heavy calcification.

STENTING OF THE ENTIRE RECANALIZED SEGMENT

The groin sheath from the left common
femoral access was upsized to 8-French 45
cm long Ansell sheath.
Two overlapping 6 mm X 15 cm Viabahn
grafts were deployed from the
intercondylar fossa and extending to the
level of proximal thigh.
A 7 mm x 10cm Viabahn graft was then
deployed from the origin of the common
femoral artery into the proximal stent
graft.
Finally the common femoral artery and
the distal external iliac artery was stented
with a 8mm diameter SMART stent.
All the Viabahn grafts were then balloon
dilated with gonadal 6 mm x 15 cm long
balloons.
Multiple dilations were performed to
expand the grafts properly.
The distal popliteal artery was balloon
dilated to 5 mm with op balloon.

INTERVENTION: ACCESS #5
THROUGH PT AND RECANALIZATION OF TP TRUNK

Finally kissing balloon dilatation of the distal popliteal

artery from the retrograde right anterior tibial access,
and a second balloon from the contralateral access
was performed to dilate the distal popliteal artery to 5
mm.

A combination of 3 mm diameter savvy and 2.5 mm

diameter sleek balloons were used.

Furthermore, the distal popliteal artery was balloon

dilated to 5 mm with opt a balloon.

The tibioperoneal trunk was balloon dilated 4 mm

diameter savvy balloon.

The proximal posterior tibial artery was balloon dilated

to 3 mm with savvy balloon.

POST INTERVENTION ANGIOGRAM

The final angiogram shows continuous
flow through the very long Viabahn stent
grafts placed from right distal external iliac
artery to the level of distal popliteal artery.

POST INTERVENTION ANGIOGRAM

Recanalization of the tibia peroneal trunk and the proximal tibial vessels resulted in widely open proximal arteries
with continuous flow into the foot.

INTERVENTION
Fluoro time: 120 minutes.
Contrast used: Isovue-300, 100cc
Estimated blood loss: 50 cc
Heparin 13,000 units
ACT: 250 to 300
Post procedure anticoagulation
Loading dose of plavix

POST INTERVENTION DISCHARGE

Aspirin 81 mg, Clopidogrel 75 mg, Coumadin 5 mg daily with target INR of 2.5-3
Continue Statin.
Strong recommendation for left lower extremity revascularization in 2-3 weeks.
Advised to start supervised exercise program since the left lower extremity
arterial disease may limit his activity.

FOLLOW UP: 2 WEEKS AFTER IR

INTERVENTION
Before
intervention

2 weeks after
intervention

Right PT

45 (0.26)

78 (0.66)

Right DP

34 (0.20)

73 (0.61)

Right ABI

0.26

0.66

ADDITIONAL INTERVENTIONS AFTER THE

INITIAL IR INTERVENTION
He underwent additional interventions in his left lower extremity.
Left lower extremity subintimal recanalization of long segment occlusion of SFA and
popliteal artery and post recanalization PTA and stenting.

He also underwent additional intervention in his right lower extremity:

Recurrent popliteal lesion requiring atherectomy, drug coated balloon angioplasty, and
stent graft placement in the right superficial femoral artery and popliteal artery.

FOLLOW-UP AND CLINICAL OUTCOME

He is much more active at home and has no pain or difficulty with
yard work outside. Tolerating supervised exercise program.

He is sleeping in his bed rather than in a chair.

He does feel that his activity now due to fatigue rather than leg pain
and feels that his stamina is increasing with exercise.

He continues on oral anticoagulation and dual antiplatelet regimen.

MOST RECENT RESULTS:

3.5 YEARS AFTER IR INTERVENTION
No symptoms
Continues regular exercises and medications
Palpable femoral and popliteal pulses and feeble
pedal pulses

No focal lesions on graft scan

Normal segmental velocities
Before
intervention

2 weeks after
intervention

Most recent
results

Right PT

45 (0.26)

78 (0.66)

1.36 (0.84)

Right DP

34 (0.20)

73 (0.61)

117 (0.72)

Right ABI

0.26

0.66

0.84

TAKE HOME POINTS

Patients with extensive proximal occlusive disease and patent tibial and pedal arteries show long term benefit from
endovascular revascularization.
Stepwise progression of recanalization with multiple accesses should be considered in heavily calcified and occluded arteries
even in the presence of stents.
Consider post stent graft intentional rupture for luminal gain.
Operator should aim to restore uninterrupted flow to to DP and plantar arch.

Operator should also strive to open two or more tibial arteries and plantar arch.
Treat both sides so the patient can start a supervised exercise program, which provides the most benefit post procedurally.
Frequent surveillance by Doppler and graft scans is essential.
Clinician should have low threshold for re-intervention with recurrence of symptoms and/or abnormal graft scans.

Patient with long segment Viabahn grafts are treated with oral anticoagulation in accordance to similar interventions
performed by vascular surgery.

REFERENCE
Conroy RM, Gordon IL, Tobis JM, et al. (2000) Angioplasty and stent placement in
chronic occlusion of the superficial femoral artery: Technique and results. J Vasc
Intervent Radiol 11:10091020.

Spinosa DJ, Harthun NL, Bissonette EA, et al. (2005) Subintimal arterial flossing
with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to
treat chronic critical limb ischemia. J Vasc Intervent Radiol 16:3744.
Spinosa DJ, Leung DA, Harthun NL, et al. (2003) Simultaneous antegrade and
retrograde access for subintimal recanalization of pheripheral arterial occlusion. J
Vasc Intervent Radiol 14:14491454.
Yilmaz S, Sindel T, Yegin A, et al. (2003) Subintimal angioplasty of long superficial
femoral artery occlusions. J Vasc Intervent Radiol 14:9971010.