Angiographic and Clinical Impact of Novel Revascularization for Occluded Femoropopliteal Prosthetic Bypass Graft: A Combination of Surgical Thrombectomy and Drug-Coated Balloon Angioplasty

Abstract

Background: Previous reports have revealed various endovascular intervention techniques for prosthetic femoropopliteal bypass occlusion (PFPBO); however, treatment for PFPBO remains challenging for most interventionalists and vascular surgeons because the procedure is complicated. Most of the reported techniques involve device implantation. In the present study, we performed a combination of surgical graft thrombectomy and drug-coated balloon angioplasty for PFPBO without implanting any additional devices. Furthermore, we determined the favorable long-term results of this treatment using follow-up angiography. Case Presentation. A 77-year-old man with a history of chronic kidney disease and coronary artery disease presented to our clinic with rest pain on his left leg. Seven years prior to the current consult, he underwent femoropopliteal bypass (FPB) surgery using a prosthetic graft due to in-stent occlusion of the left superficial femoral artery (SFA). Four years after surgery, a duplex ultrasound scan revealed stenosis of the proximal anastomosis site; hence, medical therapy was continued. On the current consult, diagnostic angiography revealed occlusion of the FPB and infrapopliteal vessels. In the first attempt at recanalization, the guidewire was unable to pass through the occluded SFA. Therefore, another technique was performed to revascularize the FPBO and infrapopliteal vessels. We obtained an angiography of the left leg after inserting the guiding sheath via the right common femoral artery (CFA). First, surgical thrombectomy using a Fogarty catheter via the exposed left CFA was performed. Following endovascular therapy via the right CFA, we performed drug-coated balloon angioplasty for anastomotic stenosis and recanalized occlusive infrapopliteal vessels. Restenosis was not observed on follow-up angiograms. On further follow-up angiography, there was notable regression of the residual stenosis at the proximal anastomosis of the prosthetic graft.

Conclusion: This novel revascularization strategy may be a viable treatment option for PFPBO.

Figure 1

The diagnostic angiography. (a) Red arrow indicates the ostium of the occluded FPB. Blue arrow indicates the ostium of the occluded DFA. (b) Blood flow was observed in the proximal part of the PA via the collateral vessels. A floating thrombus was observed in the proximal part of the PA (white arrow). The middle part of the PA and PTA was occluded (dotted line). (c) Blood flow in the plantar artery through the collateral vessels was observed. DFA: deep femoral artery; FPB: femoropopliteal bypass; PA: popliteal artery; PTA: posterior tibial artery.

Figure 2

(a) A Fogarty catheter was used to remove the thrombus in the graft. (b) DCB angioplasty using a 4 × 80 mm IN.PACT Admiral was performed on the popliteal artery. (c) DCB angioplasty using a 5 × 40 mm IN.PACT Admiral was performed on the distal anastomosis. DCB angioplasty using a 6 × 80 mm IN.PACT Admiral was performed on the proximal anastomosis. DCB: drug-coated balloon.

Figure 3

Angiograms immediately after therapy (a–e). (f) IVUS findings immediately after treatment of the proximal anastomosis. Moderate stenosis due to isoechoic plaque (yellow arrow) was noted. IVUS: intravascular ultrasound.

Figure 4

QVA of follow-up angiographies. (a) QVA of immediately after treatment. (b) QVA of 6 months after treatment. (c) QVA of 18 months after treatment. (d–g) Follow-up angiographies 18 months after treatment. QVA: quantitative vessel angiography analysis.