Successful endovascular therapy forSuccessful endovascular therapy for bilateral CLI due to Leriche syndrome
JA Hokkaido Engaru Kosei General Hospital, Japang p p
Takahide Suzuki, MD
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
BackgroundBackground
Those lesions which cause critical limb ischemia (CLI) are often multi-segment and very complex and it i diffi lt t k f l i tiis difficult to make a success of revascularization.
W i t d l CLI i hi h thWe introduce a complex CLI case, in which the combination of multi-modalities was useful.
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
Case60’s femaleDiagnosis: Critical Limb Ischemia (Rutherford 6) Caseg ( )Risk factors: Hypertension, SmokingPast Illness: Esophageal Ca. post operationPresent Illness: Both of her legs had ulceration and gangrene.
She was referred to a famous vascular surgeon at first. However, she refused any surgical therapy and was , y g pyintroduced to our hospital for endovascular therapy.
Ankle Brachial Pressure Index: R) i ibl t L) 0 28R) impossible to measure, L) 0.28
Skin Perfusion Pressure: R) impossible to measure due to severe painR) impossible to measure due to severe painL) 11-20mmHg
Right Left
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
How How do you do you treat this lesiontreat this lesion??Where is the approach from?Where is the approach from?
MSCT (MIP)
Where is the approach from?Where is the approach from?
Text
Multi-Slice CT revealed bilateral occlusion of iliac arteries
MRAarteries.
MR angiogram clearly showed total occlusion at the terminal aorta, so-called “Leriche syndrome”.
Left CFA was involved and right SFA was totally occluded
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
Left CFA was involved and right SFA was totally occluded.
How How do you do you treat this lesiontreat this lesion??Where is the approach from?Where is the approach from?
MSCT (MIP)
Where is the approach from?Where is the approach from?
Text
MRA We decided to perform revascularization for both ili t i i l di th l ft CFA t fi tiliac arteries including the left CFA at first.
As approach sites, right femoral artery and brachial artery were selected.
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
Procedure (1)For the right iliac CTORetrograde (Ipsilateral)(Ri ht f l t ) h Procedure (1)
Retrograde approach:MSCT VR and IVUS guided
(Right femoral artery) approach.
TextMSCT-VR and IVUS -guided
Guidewire
IVUS
After insertion of a 6F sheath to right CFA, a 0.018” Treasure wire (Asahi) was advanced retrogradely into the CTO of right iliac artery.
The wire was manipulated under the guidance of MSCT: virtual Volume-e e as a pu ated u de t e gu da ce o SC tua o u eRendering (VR) image, which is very helpful especially in iliac CTO.
It was advanced carefully to the aorta and the entry point was confirmed by intravascular ultrasound (IVUS) in order not to advance to the subintimal lumen.
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
Procedure (2)
For the left iliac CTO and CFAAnterograde(Brachial artery) approach Procedure (2)
Antegrade approach Ultrasound-guided wiring
(Brachial artery) approach
Antegrade approach Ultrasound guided wiring
Guidewire
A Treasure wire was advanced anterogradely to the CTO of left iliac artery.
At th f l t th i At the common femoral artery, the wire was manipulated by ultrasound guidance. It showed clearly the guidewire passage.
Finally the wire was successfully passed
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
Finally, the wire was successfully passed.
Procedure (3)Procedure (3)
TextSMART
8/100mm
SMART8/100mm
8/100mm
SMART8/60mm
SMART8/100mm
After predilatation, four SMART stents were deployed at both iliac arteries. Postdilation with a 6mm balloon-catheter and the simultaneous inflation at the
ostium of iliac artery was performed. For the left CFA lesion, balloon angioplasty was done.
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
Final ResultFinal Result
Text
Final angiogram and MSCT showed successful revascularization.
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
Clinical CourseClinical Course
Soon after the procedure 3 months later
Severe pain of her legs was relieved soon after the procedure.SPP (Skin perfusion pressure) had been improved to the sufficient value
p
( p p ) p(more than 40mmHg) in both legs.
This is why we didn’t have to perform revascularization for right SFA CTO.Ulceration was completely healed about 3 months after the procedure
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
Ulceration was completely healed about 3 months after the procedure.
What is the cause of her recurrent leg pain?
This picture showed the actual reason.
Six months later, she complained of pain and disability of her left leg again.
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
Follow–up DSA showed the restenosis of left CFA and revascularization was planned.
What is the cause of her recurrent leg pain?
After reEVT for CFA, she had operation of joint replacement.We should take care of not only artery but also bone! We should take care of not only artery but also bone!
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
SummarySummary
The important key to success in complex CLI case is to use multi-modalities effectively case is to use multi modalities effectively.
Hokkaido Engaru Hokkaido Engaru Kosei General HospitalKosei General Hospital
