Complex multilevel and multivessel endovascular revascularization through an occluded femoral-popliteal bypass in a patient with chronic limb threatening ischemia

Abstract

Chronic limb-threatening ischemia (CLTI) represents the end stage of peripheral artery disease, a problem of growing prevalence and increased health care costs around the globe. CLTI is a highly morbid disease, incurring significant mortality, limb loss, pain, and diminished health-related quality of life. The major cause of non-traumatic lower extremity amputation are related to diabetes and CLTI. Between 2% to 3% of patients with peripheral artery disease present with a severe case of CLTI, a condition that is correlated with multilevel and multivessel arterial disease, calcification, and chronic total occlusions. Multiple technical strategies to successfully cross long occlusions in arterial segments have been described. Recanalization can be performed using endoluminal, subintimal, and retrograde techniques. We report a case of complex multilevel and multivessel endovascular revascularization through an occluded femoro-popliteal bypass in a patient with CLTI.

Keywords: chronic limb-threatening ischemia; endovascular; retrograde approach; subintimal angioplasty.

Figure 1. Image showing extensive multilevel and multivessel artery disease, with presence of calcification and chronic total occlusions.

Figure 2. (A) Roadmap-guided puncture of the P3 segment of the popliteal artery; (B) Rubicon 18 support catheter and V-18 wire with a sheathless technique by inserting the femoral popliteal bypass using a retrograde approach; (C) CART technique; (D) Rendez-vous technique.

Figure 3. Final angiographic control follow-up showing good direct flow to the foot.

Figure 4. 90-day post-angioplasty Doppler echocardiograph. (A) B mode: Stent in the popliteal artery with no signs of fracture; (B) Doppler: Stent with laminar flow, with no turbulences or signs of neointimal hyperplasia; (C) B mode: Distal popliteal artery with no significant atherosclerotic plaques; (D) Doppler of distal popliteal artery: Three-phase curve with peak systolic velocity of 74 cm/s.

Figura 1. Se observa extensa enfermedad arterial multinivel y multivaso, con presencia de calcificación y de oclusiones totales crónicas.

Figura 2. (A) Punción guiada por roadmapping del segmento P3 de la arteria poplítea; (B) Catéter Rubicon 18 y guía V-18 con técnica sin introductor (sheathless) ingresando al bypass fémoro-poplíteo por vía retrógrada; (C) Técnica CART; (D) Técnica rendezvous.

Figura 3. Control angiográfico final con buen flujo directo hacia el pié.

Figura 4. Ecografía Doppler a los 90 días post-angioplastia. (A) Modo B: Stent en arteria poplítea sin señales de fractura; (B) Doppler: Stent con flujo laminar, sin turbulencias ni señales de hiperplasia neointimal; (C) Modo B: Arteria poplítea distal sin placas aterosclerótica significativas; (D) Doppler arteria poplítea distal: Curva trifásica con velocidad de pico sistólica de 74 cm/s.