Patient Background

A 65-year old male with a history of severe PAD developed rest pain involving the right lower extremity. Non-invasive testing demonstrated an ABI of .54 on the right limb. Duplex ultrasound confirmed severe occlusive disease of the superficial femoral and popliteal arteries. The anterior tibial and posterior tibial arteries were also occluded. His symptoms were consistent with critical limb-threatening ischemia; therefore, he was scheduled for peripheral intervention.

Procedure

Left common femoral artery access was obtained, and the up and over technique was used to engage the right external iliac artery. The right lower extremity angiogram showed mild common femoral artery plaque and 100% ostial occlusion of the SFA with reconstitution at the distal posterior tibial artery. A (6x45cm) Destination sheath was advanced over a Magictorque wire to selectively engage the right common femoral artery. Wire and catheterbased crossing strategies were used to successfully cross the occluded vessels into the distal posterior tibial artery. A (6x45cm) Destination sheath was advanced over a Magictorque wire to selectively engage the right common femoral artery. Wire and catheterbased crossing strategies were used to successfully cross the occluded vessels into the distal posterior tibial artery. Laser atherectomy was then performed for plaque modification in the SFA and popliteal arteries using a 2mm Turbopower catheter. Drug coated balloon angioplasty was then used in the femoropopliteal segment using IN.PACT balloons with less than 20% residual stenoses.

Conclusion

Final angiogram showed minimal residual disease in the SFA/popliteal and posterior tibial arteries. Serration angioplasty with the Serranator balloon in the TPT/PT vessels yielded substantial luminal gain with good blood flow and without dissection or the need for bailout stenting.