Abstract
Peripheral embolization is a known complication of peripheral artery interventions. It can lead to occlusion of distal vessels leading to significant lower extremity ischemia and complications. Peripheral artery interventions involving chronic total occlusions have been shown to have higher rates of complications including distal embolization. Although distal embolic protection strategies are available, they are seldom utilized during lower extremity interventions, especially during treatment of totally occluded vessels. Proteus embolic capture angioplasty balloon may provide operators with the option of balloon dilation of stenotic lesion in the peripheral arterial bed, along with embolic capture. We report a case where use of this novel device helped in achieving a successful angioplasty outcome along with evacuation of distal embolus and restoration of antegrade flow.
1
Introduction
Estimates of the prevalence of peripheral artery disease (PAD) in the general US adult population vary widely . These estimates range between 5 and 10 million adults affected. Lower limb peripheral artery interventions (PAIs) are being performed in growing numbers every year, with more novel devices and techniques being developed to improve procedural success and patient safety . Increasingly, complex patients with multiple comorbidities and severe forms of PAD are being considered for PAI. Minimizing the risk of potential complications, especially in high-risk procedures, is a necessity. Peripheral embolization (PE) is a common complication of PAI . Distal embolization can lead to occlusion of distal vessels leading to significant lower extremity ischemia and complications . The Proteus device is a novel embolic capture device for use in PAI. It performs as an angioplasty balloon combined with an embolic capture feature.
2
Case
A 59-year-old man with diabetes mellitus and severe PAD with long-standing lifestyle-limiting left lower extremity claudication (Fontaine class IIb) was referred for diagnostic angiography and intervention. Ankle brachial indices on right lower extremity were 0.68 and 0.00 on the left, given absent distal pulses. Access to the left superficial femoral artery (SFA) was obtained contralaterally with a 6F, 90-cm sheath. Diagnostic angiography revealed severe diffuse disease of the distal left SFA occlusion with reconstitution at the level of the left tibioperoneal trunk and antegrade flow in the left anterior tibial and peroneal arteries ( Fig. 1 ). Crossing of the occluded segments of the distal left SFA and popliteal arteries occlusion was achieved using a CrossBoss blunt microdissection catheter ( Fig. 2 ). Angiography of the target vessels after successful crossing of the occlusion revealed patent left popliteal artery segment with severe diffuse residual disease and an abrupt ‘cutoff’ in the proximal segment of the left anterior tibial artery, consistent with an embolic occlusion ( Fig. 3A ). A 6-mm×60-mm Proteus embolic capture balloon was then advanced to the left popliteal artery and inflated to 12 atm for 60 s ( Fig. 3A ). The balloon was then deflated to 2 atm, and inward folding and debris capture were performed by retraction of the device handle, following which the balloon was completely deflated and removed. The evacuated balloon was unfolded, and the debris was stained with hematoxylin–eosin on a filter. Angiogram performed post-Proteus angioplasty revealed good angiographic result with mild residual stenosis in the left popliteal artery and restored antegrade flow in the left anterior tibial artery ( Fig. 3C ). The evacuated macroscopic debris is shown in Fig. 4 . The mid and distal segments of left SFA were eventually stented using a 6.0-mm×150-mm SMART self-expanding stent. The stent was postdilated using a 5.0-mm×150-mm balloon with an excellent final angiographic result.
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