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Case presentation:Critical Limb Ischemia
Subhash Banerjee, MD
VA North Texas Health Care &
UT Southwestern Med. Ctr.
Dallas, TX
Strategies on the Frontline
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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
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Diagnostic angiographic images
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Diagnostic angiographic images
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Initial unsuccessful attempt
Contralateral CFA access6F Crossover sheathPrimary GW/support catheter crossing
Escalation of symptomsafter failed attempt
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Repeat attempt in 4 weeksAntegrade access with 6F45 cm sheath
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Primary crossing with Viance catheter
Right lateral view
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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
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Subintimal passage and re-entry with Enteer
Successful TP trunk re-entry with Enteer catheter & wireFollowed by IVUS confirmation
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IVUS confirmation of distal true lumen access
Compressed true lumen atheroma
Sub-intimal space s/p balloon dilation
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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
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Final result after distal SFA & TP trunk stenting
6x40mm nSES
Two 3x38mm DES
Significant improvement in patient symptoms at 3m F/U