Abstract
Introduction
Percutaneous endovascular revascularization requires the use of fluoroscopic guidance and radiopaque contrast. We present a successful intervention without the use of iodinated contrast.
Case
A 92-year-old man with dry gangrene involving the second and fourth left toes had acute on chronic kidney injury. Arterial duplex showed severe stenosis in bilateral superficial femoral arteries (SFAs). Fluoroscopic and ultrasound guidance and intravascular imaging were used to avoid iodinated contrast. After right to left femoral crossover, the entire left SFA was imaged with ultrasound. The lesion was delineated with radiopaque measuring tapes then wired. Near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS) imaging were performed. Points of interest were correlated with corresponding radiopaque markings on the ruler. Stenting and post-dilation resulted in complete stent expansion and no evidence of dissection by IVUS. The total procedure time was 113 min and the total radiation dose 813 mGy. The day after the procedure, there was a palpable dorsalis pedis pulse. He was discharged to inpatient rehabilitation on dual antiplatelet therapy.
Discussion
Contrast and radiation continue to limit the feasibility of endovascular angiography and intervention. Carbon dioxide (CO2) digital subtraction angiography is an alternative for these patients but has several disadvantages. Previously proposed projects demonstrated the real potential of performing endovascular peripheral intervention without fluoroscopy or contrast.
Conclusion
This case is a clear demonstration of a successful use of a combination of fluoroscopy, ultrasonography and intravascular imaging to achieve a successful endovascular intervention to treat critical limb ischemia, without the use of iodinated contrast.
1
Introduction
Percutaneous endovascular revascularization is increasingly becoming the preferred treatment option for symptomatic peripheral arterial disease. It is also associated with a high success rate, low in-hospital complication rate, and acceptable restenosis rate at medium-term follow-up. However, this strategy requires the use of fluoroscopic guidance and radiopaque contrast, and may be problematic in patients with advanced renal disease or allergies to iodinated contrast medium. We present a case of successful endovascular intervention to treat a patient with critical limb ischemia without the use of iodinated contrast; the case represents a novel step forward in the use of multi-modality imaging co-registration to minimize the harmful effects of contrast and radiation exposure.
2
Case
The patient is a 92-year-old man with a history of coronary artery disease status post coronary artery bypass grafting, diastolic heart failure, atrial fibrillation, carotid artery disease (right carotid stenosis, left carotid occlusion), hypertension, hyperlipidemia, and stage IV chronic kidney disease (baseline creatinine 2.7 mg/dl) who was brought to our medical center from a nursing home with left foot pain and ulceration.
On physical examination, vital signs were normal. Bilateral femoral pulses were normal; bilateral popliteal and pedal pulses were not palpable. The left foot was cool, with dry gangrene involving the second and fourth toes as well as multiple pressure point ulcerations in the left foot and lower left pretibial region. Laboratory evaluation was significant for hemoglobin of 7.9 mg/dl, and acute on chronic kidney injury with a blood urea nitrogen of 89 mg/dl and a creatinine of 3.61 mg/dl. Lower extremity arterial duplex showed normal bilateral common femoral artery waveforms, and severe stenosis in bilateral superficial femoral arteries (SFAs). Absent left toe pressure was noted. In view of Rutherford 5 critical limb ischemia, the decision was made to revascularize the threatened limb. Because of worsening renal failure, a strategy combining fluoroscopic and ultrasound guidance as well as intravascular imaging was devised to perform the intervention without iodinated contrast.
In the catheterization laboratory, a 5-French short sheath was placed in the right common femoral artery using micropuncture technique and ultrasound guidance. Right to left femoral crossover was performed with a 5-French rim catheter and Glidewire Advantage wire (Terumo, Somerset, NJ). A 6 French × 45 cm Flexor® Ansel sheath (Cook, Bloomington, IA) was positioned in the left common femoral artery. At this point the entire left SFA was imaged with ultrasound. The proximal and distal margins of the lesion were delineated with radiopaque measuring tapes. A 0.014″ guidewire crossed the lesion easily, and was parked in the left posterior tibial artery. Near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS) imaging were then performed with a TVC catheter (InfraReDx, Burlington, MA), beginning from the proximal popliteal, into the proximal-mid SFA. This revealed relatively disease-free proximal and distal reference segments with lumen diameters ranging from 5 to 6 mm. The lesion length was approximately 15 cm. There was no significant lipid burden by NIRS. The NIRS-IVUS points of interest were correlated with corresponding radiopaque markings on a ruler taped to the thigh. The lesion was pre-dilated with a 4.0 × 60 mm Advance 18 balloon (Cook, Bloomington, IA). Two overlapping Zilver PTX stents (Cook, Bloomington, IA) were deployed: 7 × 100 mm (distal) and 7 × 80 mm (proximal). The distal stent was post-dilated with a 5 × 60 mm Advance 18 balloon (Cook, Bloomington, IA) and the proximal stent was dilated with a 6 × 30 mm Viatrac 14 Plus balloon (Abbott Vascular, Santa Clara, CA). At the end of the procedure, there were complete stent expansion and no evidence of dissection by IVUS. For documentation and comparison purposes, selective left femoral angiography was performed using CO2 injected through the sheath ( Fig. 1 ). It confirmed 0% residual stenosis with brisk antegrade flow. The proximal posterior tibial and anterior tibial arteries were patent. All tibial vessels were occluded distally. The dorsalis pedis reconstitutes in the foot and was patent. No other pedal vessels were visualized. The 6 French × 45 cm sheath was exchanged for a short 6 French sheath which was sutured in place with manual pressure planned for hemostasis. The total procedure time was 113 min with a total radiation dose of 813 mGy and no iodinated contrast was used. On the day after the procedure, there was a palpable left dorsalis pedis pulse. He was discharged to inpatient rehabilitation on dual antiplatelet therapy.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
