Case presentation:Critical Limb Ischemia

Subhash Banerjee, MD

VA North Texas Health Care &

UT Southwestern Med. Ctr.

Dallas, TX

Strategies on the Frontline

Case presentation

• 77 year old diabetic male Veteran with presents with c/o a “deep sensation of pain” in his right calf

• Partial relief is often obtained by taking a short walk around the room

• Right coronary artery PCI 6 months ago• Continues to smoke cigarettes• ABI: 0.5 (B/L); ankle pressure 52 mm Hg

Diagnostic angiographic images

Diagnostic angiographic images

Initial unsuccessful attempt

Contralateral CFA access6F Crossover sheathPrimary GW/support catheter crossing

Escalation of symptomsafter failed attempt

Repeat attempt in 4 weeksAntegrade access with 6F45 cm sheath

Primary crossing with Viance catheter

Right lateral view

Viance blunt microdissection catheter

Torque Handle

Torque Handle

Distal Catheter Tip (rounded, atraumatic, 1 mm)

(a)

(b)

0.014” guidewire (300 cm)

135 cm shaft (2.3F)0.035 OD: compatible with most support catheters

Subintimal passage and re-entry with Enteer

Successful TP trunk re-entry with Enteer catheter & wireFollowed by IVUS confirmation

IVUS confirmation of distal true lumen access

Compressed true lumen atheroma

Sub-intimal space s/p balloon dilation

Enteer re-entry catheter

Orienting balloon with radio-opaque markers indicating wire-exit ports on diametrically opposite sides of the balloon

Stingray GW with 0.0035” distal taper

Final result after distal SFA & TP trunk stenting

6x40mm nSES

Two 3x38mm DES

Significant improvement in patient symptoms at 3m F/U