Balloon-oriented puncture for creating an access for endovascular aortic aneurysm repair in a case of iliac and femoral artery occlusion

Arterial Embolic Complications in a Patient with Acute Heart Failure

Introduction: In acute heart failure patients, the prothrombotic state is likely due to arterial and venous endothelial dysfunction. Decompensated heart failure appears to also be associated with increased levels of prothrombotic molecules, such as fibrinogen and von Willebrand factor, which also contribute to the prothrombotic state.

Case presentation: We present the case of a 72-year-old male patient, admitted for signs of acute heart failure with bilateral ankle edema. Laboratory data showed D-dimer level >5 µg/mL, which raised the suspicion of pulmonary embolism secondary to deep vein thrombosis. Doppler ultrasound performed to exclude a deep vein thrombosis revealed a total occlusion of the superficial femoral artery on the lower left limb and an abdominal aorta with a lumen diameter of 35 mm and a true lumen of 18.6 mm with circular isoechoic material on the aortic wall. The computed tomography angiography described an aneurysm of the abdominal aorta with mural thrombosis extending to the bifurcation level.

Conclusion: In patients with acute heart failure, a comprehensive vascular assessment is also needed. The therapeutic management of these patients varies from conservative to endovascular or surgical therapy, but revascularization therapy should be considered based on the patient’s medical condition.

Open Proximal Endarterectomy with Retrograde Access and Stenting: A Novel Technique for Lower Extremity Revascularization

BACKGROUND

Treatment of chronic limb threatening ischemia (CLTI) poses a significant clinical challenge despite recent medical advancements. Chronic total occlusion (CTO) lesions make endovascular approaches to CLTI particularly challenging. Open proximal exposure with retrograde access and stenting (OPERAS) aims to solve this challenge through retrograde subintimal crossing of a CTO with direct visualization of proximal re-entry into the true lumen. We describe this novel technique and present its efficacy in eight patients.

METHODS

We conducted a retrospective case series at a single tertiary academic center. Data for patients who received OPERAS intervention included demographics, peri-operative details, and follow-up information. Statistical analysis was performed on length of stay, major post-operative complications, further intervention, clinical progression at 1 year, and amputation-free survival at 1 year. Immediate technical failure (ITF) and limb-based patency (LBP) at 1 year were calculated.

RESULTS

Nine limbs underwent OPERAS between January 2019 and March 2020. Inflow was achieved with common femoral artery endarterectomy. All limbs underwent balloon angioplasty and stenting of the SFA, and seven underwent the same procedure in the popliteal artery. ITF was 0% for all nine cases. There were no major post-operative complications, and ankle-brachial index significantly improved pre-and post-operatively (P < .001). Eight limbs (88.9%) sustained amputation-free survival at 1 year, and overall LBP was 67% at 1 year.

CONCLUSION

Our study presents a hybrid revascularization option to address severe, anatomically complex limbs (GLASS III) that lack a single autogenous conduit for open surgical revascularization. OPERAS addresses a main point of technical failure of subintimal techniques by directly visualizing the wire in the true lumen. Our data suggest that OPERAS can be effective to: (1) improve technical success of luminal re-entry following a subintimal approach; (2) address inflow concurrently with severe femoropopliteal disease; and (3) can be utilized when distal tissue loss is involved.

Direct puncture of an occluded common femoral artery as a new approach for endovascular aortic aneurysm repair

Background

Abdominal aortic aneurysms (AAA) which present with a hostile access are not uncommon. When an arterial occlusion continuously involves from the iliac to the femoropopliteal artery, endovascular aneurysm repair (EVAR) can become complex, necessitating an adjunctive surgical procedure. The present report outlines a successful EVAR which was conducted without any adjunctive surgical procedure for an AAA complicated by extensive access vessel occlusion.

Case presentation

The patient, an 82-year-old male, had a fusiform 50 mm infrarenal AAA. He had a history of above knee amputation of the right leg due to a gangrene from Buerger’s Disease. Despite the continuous occlusions of the right external iliac artery (EIA), common femoral artery (CFA), and superficial femoral and profunda femoris artery, limb ischemia was not observed in his right leg. Since revascularization of the occluded right iliac and femoral arteries was deemed to be too complex technically and no ischemic symptoms were observed, EVAR was performed using the occluded access only for the delivery of the stent graft without restoring the flow. Firstly, the occluded right CFA was punctured under ultrasound guidance. Next, a 0.014 in. guidewire and a microcatheter were successfully navigated to the subintimal space of the right common iliac artery (CIA), these were then exchanged with a reentry device. The reentry device allowed the advancement of a guidewire into the true lumen of the right CIA. Then, a 12Fr sheath for delivery of a contralateral limb was advanced via the occluded right access to aorta, and a 16 Fr sheath for delivery of a main body graft was advanced via a patent left iliac artery. A standard EVAR procedure was subsequently performed.

Conclusions

EVAR was successfully performed for an AAA complicated with an arterial occlusion from the EIA to the SFA using direct puncture of the occluded CFA. This technique could be an effective measure for cases with a hostile access involving the CFA.