Delayed rupture of peroneal artery pseudoaneurysm following endovascular treatment in a patient with chronic limb-threatening ischemia: A case report

Below-the-knee (BTK) pseudoaneurysms that occur after endovascular therapy (EVT) and result in delayed rupture have rarely been reported. In this report, we present a rare case of an 86-year-old man with chronic limb-threatening ischemia who developed delayed rupture of an idiopathic pseudoaneurysm of the peroneal artery (PA) following EVT. The PA chronic total occlusion (CTO) was successfully crossed using a guidewire via an antegrade approach, however, subintimal crossing was confirmed by intravascular ultrasound. Balloon angioplasty was then performed using an appropriately sized balloon, resulting in successful recanalization of the PA CTO with minor dissection and no complications. Postoperatively, the patient's condition was stable until he suddenly complained of right calf pain 10 days after EVT. Computed tomography revealed a rupture of the PA pseudoaneurysm. Urgent angiography revealed two pseudoaneurysms, one saccular and the other spindle-shaped. The ruptured saccular aneurysm was successfully excluded through coil embolization and stent graft placement. To the best of our knowledge, this is the first reported case of delayed rupture of a BTK pseudoaneurysm following EVT. Balloon angioplasty in the subintimal space can lead to the formation of a pseudoaneurysm and its delayed rupture.     

New endovascular technique for thrombus in the non‐stenting zone—the Grab a Clot and Hold ON “(GACHON) technique”: Case report

It is difficult to treat a thrombotic embolism in the common femoral artery or popliteal artery (POP A), i.e., the non‐stenting zone. We report a new technique for the treatment of thrombotic embolism in the non‐stenting zone using a self‐expandable nitinol stent. Case 1 had an external iliac artery (EIA) occlusion that occurred over several months. A self‐expandable nitinol stent was placed in the right EIA lesion via a retrograde approach using a distal 9‐Fr balloon protection guide catheter in the right femoral artery. A thrombotic embolism occurred at the balloon protection site. It was too big to be removed using an aspiration catheter; therefore, we attempted removal with a self‐expandable stent. Using a crossover approach, we delivered a nitinol self‐expandable stent to the distal site of the thrombus, opened the tip of the stent, and pulled it up to the proximal site. Finally, we “grabbed a clot,” moved it to the stenting zone, and “held on” the vessel wall without occurrence of a distal embolism. We named this the “GACHON technique.” Case 2 underwent endovascular therapy for an acute thrombotic embolism in POP A after thoracic endovascular aortic repair for dissection. This thrombus was too big to aspirate, and we successfully treated it using the “GACHON technique.” The “GACHON technique” may be considered as a choice of treatment for a thrombotic embolism in the non‐stenting zone. © 2016 Wiley Periodicals, Inc.     

Imaging a spiral dissection of the superficial femoral artery in high resolution with optical coherence tomography—Seeing is believing

Optical coherence tomography (OCT) offers an alternative to intravascular ultrasound (IVUS) for endovascular imaging. Clinical and research applications for OCT have emerged in percutaneous coronary intervention (PCI), however, OCT has not found similar utility in peripheral arterial interventions. Early generation time‐domain OCT systems required arterial occlusion to create the blood free environment needed for image acquisition and could not reliably scan vessel diameters encountered in the peripheral circulation. However, the frequency‐domain OCT (FD‐OCT) system currently FDA approved for use in the United States does not require arterial occlusion to generate images and permits a greater scan diameter allowing for exploratory use in peripheral arteries. To our knowledge, this is the first report using non‐occlusive OCT imaging to serve as an adjunct to endovascular intervention for femoropopliteal disease. We illustrate the feasibility of acquiring high resolution images of a spiral dissection of the superficial femoral artery following balloon angioplasty that was not adequately visualized by angiography. © 2012 Wiley Periodicals, Inc.     

Delayed superficial femoral artery pseudoaneurysm following distal femoral shaft fracture: a case report

A 69-year-old man presented with an expanding tissue mass over the medial aspect of his left thigh 6 weeks after a fracture of the distal femur shaft. Imaging studies confirmed a rare traumatic pseudoaneurysm of the superficial femoral artery. For the massive hematoma and persistent exsanguinating hemorrhage, staged interventions were taken. First, the pseudoaneurysm was hemodynamically isolated with an endovascular stent-graft placement. Subsequent surgical exploration and aneurysmectomy were performed later for the evacuation of the formed hematoma and the relief of the resultant compressive symptoms. Because traumatic pseudoaneurysm can have an insidious onset and delayed presentation, surgeons should consider the possible complication even after initial fracture fixation.     

Percutaneous revascularization of long femoral artery lesions for claudication

Background : Angioplasty and stenting are preferred treatments for revascularizing femoral artery lesions up to 100 mm, but surgical bypass is recommended for longer lesions. We assessed long‐term patency after percutaneous revascularization of long femoral artery lesions for claudication with intensive out‐patient surveillance. Methods : We followed a cohort of 111 consecutive patients receiving angioplasty or stenting in 142 limbs in two institutions. Patients were followed for 2.5 years, and event curves and multivariable survival analysis used to compare outcomes in three groups according to lesion length (< 100 mm, 100–200 mm, and greater than 200 mm). Failed patency was defined as recurrence of symptoms with a decline in ankle brachial index, or stenosis identified by duplex ultrasound, or reintervention. Results : Compared to lesions less than 100 mm, longer lesions had higher failed primary patency (100–200 mm: HR = 2.0, P = 0.16, >200 mm: HR = 2.6, P = 0.03). Failed secondary patency was similar for short and intermediate lesions (< 5% incidence), but trended higher for lesions >200 mm (HR = 4.2, P = 0.06). An initial procedure residual stenosis greater than 20% was the only significant multivariable factor related to poorer long‐term patency (HR = 15.8, P = 0.003). Compared to short lesions, the gain in long‐term patency with out‐patient surveillance and reintervention was higher for longer lesions and significantly so for intermediate lesions (100–200 mm = 23% versus <100 mm = 8%, P = 0.041). Conclusion : Percutaneous treatment of long femoral artery lesions can provide acceptable long‐term patency for patients with claudication when out‐patient surveillance is used to identify patients who require repeat interventions. Future long‐term studies should consider overall patency encompassing more than one percutaneous reintervention. © 2011 Wiley‐Liss, Inc.     

Catheter‐directed therapy for acute renal vein thrombosis in systemic lupus erythematosus: A case report

We report our experience using catheter‐directed thrombectomy/thrombolysis (CDT) to treat a patient with acute renal vein thrombosis (RVT) associated with systemic lupus erythematosus (SLE). A 34‐year‐old woman presented with persistent left flank pain, and a renal ultrasonography examination revealed an enlarged left kidney. Contrast‐enhanced computed tomography confirmed the presence of acute left RVT. Because medical treatment failed to relieve her pain and the renal function was deteriorating, we attempted to salvage the occluded left renal vein using an endovascular approach. The pain was completely relieved after a CDT and an overnight urokinase infusion. A follow‐up computed tomography examination revealed the complete resolution of the thrombus. The creatinine level returned to normal (1.7–0.4 mg/dL), along with contrast enhancement in the left kidney, and this suggested the preservation of renal function. To our knowledge, this is the first report utilizing CDT to treat SLE‐associated RVT. When the renal function is deteriorating, CDT is worth considering for RVT if conventional medical treatment has failed. © 2016 Wiley Periodicals, Inc.     

Cutting balloon recanalization for femoral artery stenosis in a child: a case report.

A chronic femoral artery stenosis associated with an ipsilateral leg length discrepancy was found resistant to high-pressure balloon angioplasty. Improvement in vessel caliber and relief of the stenosis were achieved after a cutting balloon.     

Endovascular stenting for treatment of a left internal mammary artery pseudoaneurysm following redo‐sternotomy: A case report

An 85‐year‐old gentlemen with a history of previous triple vessel coronary bypass grafting presented with severe aortic stenosis and occlusion of the previous saphenous vein grafts but with patent left internal mammary artery (LIMA)–left anterior descending. The patient underwent uncomplicated repeat sternotomy and aortic valve replacement with repeated coronary bypass. On post‐operative day 21 the patient was successfully resuscitated from a pulseless electrical activity (PEA) arrest, and was found to have a 1‐cm pseudoaneurysm of the left internal mammary artery at the level of sternomanubrial junction with associated hemothorax. The LIMA remained patent and a pinhole source of extravasation was discovered by angiography at the aneurysmal site. The defect was successfully repaired by endovascular implant of a 3.5 mm × 12 mm Graft Master covered stent (Abbott Vascular). The patient recovered well from the procedure without further complications and was discharged after a total of 48 days of hospital stay. Our experience confirms the feasibility of repairing post‐operative pseudoaneurysm in the internal mammary artery by endovascular stent grafting, thereby avoiding the risks and complications of a repeat open chest procedure. © 2013 Wiley Periodicals, Inc.     

A prospective,multi‐center study of the chocolate balloon in femoropopliteal peripheral artery disease: The Chocolate BAR registry

The Chocolate BAR study is a prospective multicenter post‐market registry designed to evaluate the safety and performance of the Chocolate percutaneous transluminal angioplasty balloon catheter in a broad population with symptomatic peripheral arterial disease. The primary endpoint is acute procedural success (defined as ≤30% residual stenosis without flow‐limiting dissection); secondary long‐term outcomes include freedom from target lesion revascularization (TLR), major unplanned amputation, survival, and patency. A total of 262 patients (290 femoropopliteal lesions) were enrolled at 30 US centers between 2012 and 2014. The primary endpoint of procedure success was achieved in 85.1% of cases, and freedom from stenting occurred in 93.1%. Bail out stenting by independent adjudication occurred in 1.6% of cases and there were no flow limiting dissections. There was mean improvement of 2.1 Rutherford classes (±1.5) at 12‐months, with 78.5% freedom from TLR, 97.2% freedom from major amputation, and 93.3% freedom from all‐cause mortality. Core Lab adjudicated patency was 64.1% at 12 months. Use of the Chocolate balloon in an “all‐comers” population achieved excellent procedural outcomes with low dissection rates and bailout stent use.     

Renal artery stenosis and ambulatory blood pressure monitoring: A case report and review of the literature

Renal artery stenosis (RAS) is a prevalent cause of secondary hypertension. Elderly patients with atherosclerosis and young women with fibromuscular dysplasia (FMD) are particularly at risk. Blood pressure screening is often key to this diagnosis, although the reliability of clinical screening has been questioned, and ambulatory blood pressure monitoring (ABPM) likely offers superior ability to diagnose poorly controlled hypertension. In patients with RAS, medical management should be the primary means of therapy; however, in a select group of these patients, renal revascularization may be considered, and has been shown to reduce blood pressure and stabilize chronic kidney disease. In this report, we present a patient diagnosed with RAS due to FMD, found to have significant hypertension via ABPM, and treated successfully with percutaneous renal artery angioplasty; importantly, continuous 24‐hr ambulatory monitoring after pressure gradient guided renal angioplasty confirmed reduction in blood pressure.     

Transradial stenting of the iliac artery: a case report.

In this case report, stenting of the common iliac artery via the radial access route with 6 Fr equipment, including an extra long multipurpose catheter, is presented. Radial access avoids bleeding and ischemia that may complicate retrograde or crossover access to the iliac artery.     

Percutaneous transluminal angioplasty via dorsalis pedis artery for chronic total occlusion of superficial femoral artery: a case report

A 60-year-old woman with intermittent claudication underwent angiography, which showed total occlusion of the left superficial femoral artery and no distal flow. Computed tomography with contrast medium revealed that the occlusion extended to the popliteal artery but distal flow was maintained to the dorsalis pedis artery. Percutaneous transluminal angioplasty was attempted via the right femoral artery, but the guidewire could not be advanced. Therefore, a 4F sheath was inserted into the dorsalis pedis artery and the guidewire was passed through the occluded lesion. After pre-dilation, the guidewire was re-crossed from the right femoral artery and two stents were successfully implanted. Finally sufficient antegrade blood flow was achieved after the procedure. The trans-dorsalis pedis artery approach is a valuable option for the percutaneous transluminal angioplasty of long superficial femoral artery occlusion if the antegrade approach is impossible.