Abstract
Peripheral artery disease (PAD) and chronic kidney disease (CKD) commonly occur together and are known to lead to poor long-term survival. Furthermore, it is not yet known whether percutaneous catheter intervention for PAD using contrast agents is beneficial or not for such patients. The risk of CKD patients contracting contrast-induced nephropathy due to the use of contrast agents is frequent. We report a patient with diabetes and CKD in whom a chronic total occlusion lesion of superficial femoral artery was successfully managed with catheter treatment without the use of contrast agents, using various modalities.
1
Introduction
The technological advances associated with endovascular treatment for peripheral artery disease (PAD) have led to an expansion in indications, and this approach is now becoming the core method for treating PAD. The Trans-Atlantic Inter-Society Consensus II (TASC II) report in 2007 expanded the indications for endovascular treatment, and the treatment strategy regarding the femoropopliteal arterial region has been comprehensively revised. Femoral artery occlusive lesions that are under 5 cm long have been classified as Type A, and catheter treatment is now recommended. Initial success rates have improved to over 96% . However, endovascular approaches are associated with an increased risk of occurrence of contrast-induced nephropathy (CIN). In particular, patients with chronic kidney disease (CKD) have every possibility of CIN due to use of contrast agent . We report a successful intervention without the use of contrast agents in a case of superficial femoral artery (SFA) chronic total occlusion (CTO), for which various modalities were used.
2
Case report
The subject was an 80-year-old diabetic male who had a previous anterior myocardial infarction. The patient experienced intermittent claudication in both lower limbs from about August 2008, and his ankle–brachial index (ABI) was significantly decreased at 0.62 on the right and 0.57 on the left. Duplex ultrasound and magnetic resonance imaging (MRI) confirmed that the SFA was completely occluded on both sides ( Figs. 1 and 2 ). The patient requested revascularization treatment as the symptoms had worsened. He had renal dysfunction due to diabetic nephropathy, and the preoperative serum Cr value was high, at 1.8 mg/dl. Estimated glomerular filtration rate was low at 36.49 ml/min/1.73 m 2 , and the patient was diagnosed as having stage 3 CKD. The occlusion length measured by ultrasound and MRI was 30 cm on the left side and 10 cm on the right, and was determined by the TASC classification to be type D on the left and type B on the right. We recommended a bypass operation because of the complication of CKD, but the lesions were treated using a catheter technique due to an emphatic request by the patient.
First, intervention was performed on the CTO lesion in the left SFA because symptoms were greater on this side. Sufficient physiological saline was given starting on the day before treatment. We decided to perform the intervention using an antegrade approach from the contralateral femoral artery. A 6-Fr sheath was inserted into the right femoral artery, and the catheter was inserted until it reached the left iliac artery. The amount of contrast agent was kept as low as possible by various methods because of the risk of nephropathy. Imaging with minimum contrast before treatment showed occlusion of the SFA about 5 cm from the branch point with the deep femoral artery. Collateral flow led to definition of the popliteal artery ( Fig. 3 ). Using duplex ultrasound, we initiated wiring of the CTO lesion ( Fig. 4 ). The sheath was advanced to the femoral artery, and using a 4-Fr catheter (Tempo 4 Fr, Johnson and Johnson) and a microcatheter (Progreat β; Terumo, Japan), a 0.014-in. soft wire (Neo’s Rinato; Asahi Intecc, Japan) was passed into the inner region of the CTO. The wire reached an extremely hard lesion within the lower part of the SFA and was changed to a 0.018-in. 30-g wire (Neo’s Astato, Asahi Intecc). However, the wire did not penetrate into the distal true lumen and ran in the subintimal space. To obtain reentry of the wire into the true lumen at the distal end of the CTO, we used IVUS to determine the direction. With the reference point of IVUS imaging, showing that the wire was in the false lumen of the distal part of the CTO, we manipulated another wire (Astato XS 9-12, Asahi Intecc) ( Fig. 5 ), which succeeded in penetrating the distal true lumen. After dilation using a 6-mm balloon (Sterling 6.0×60 mm, Boston Scientific), three self-expandable stents (SMART 6.0×100 mm, 7.0×100 mm, 7.0×100 mm; Johnson and Johnson) were deployed and good expansion was observed ( Figs. 6 and 7 ). Flow, as measured by laser flowmeter, showed an increase, and there was no pain in the lower limb or change in color. There was an improvement in the palpable dorsal artery of the foot, and the procedure was considered finished because there were no complications such as slow flow or vessel rupture. The total amount of contrast agent used was just 40 ml. The postoperative ABI improved to 0.84. There was no postoperative increase in serum creatinine.
One week later, the right SFA CTO was treated. We decided upon a bidirectional approach, combining an antegrade approach from the ipsilateral femoral and a retrograde approach from the popliteal artery. The aim of this treatment was to treat the SFA CTO without any use of contrast agent, if possible. The wire was advanced using a Duplex US guide. The first wire, a 0.018-in. 12-g Treasure (Asahi Intecc), was changed to a 0.018-in. 30-g wire (Neo’s Astato, Asahi Intecc) when the tip was stacked. We manipulated the wire while trying to keep the tip of the wire in the middle of the vessel on the long axis view. When the tip disappeared, the short axis view was used to check the location of the wire. We reentered the distal lumen, penetrating the distal fibrous cap. The wire was advanced further to the sheath of the popliteal artery and was progressed to outside the body ( Fig. 8 ). After dilation of a 2.5-mm balloon (Submarine Plus 2.5×80 mm, Invatec), IVUS confirmed that the wire passed through the center of the plaque and was not located within the edge of the vessel. After dilatation of a 5.0-mm balloon (Submarine Plus 5.0×80 mm, Invatec), the lumen was again checked with IVUS, showing generally good dilation and just a mild degree of dissection ( Fig. 9 ). At this point, there was no pain in the femoral region, the peripheral arteries were clearly palpable, and the laser flowmeter value had improved. Using CO 2 gas for imaging, distal flow was good and no extravasation was found ( Fig. 10 ). The pressure gradient between the tip of the sheath at the femoral artery and the sheath in the popliteal artery was 0 mmHg, and as the results were deemed to be satisfactory with balloon dilation alone, the procedure was concluded. Thus, treatment of the right SFA CTO was performed without any use of contrast agent. No postoperative complications were encountered, the ABI improved to 0.92 and intermittent claudication disappeared.
