Peripheral

Approach: puncture of stented femoral artery

Analyze the CT angiography of this 85 year-old claudicant male patient with HTA, PAD, bilateral common iliac and right CFA lesions, and tell us how you would treat!

Yann Gouëffic
Yann Gouëffic
Hospital: Paris Saint-Joseph, France

Professor of Vascular Surgery 
President of the association of the french university hospitals for clinical research 

Conflicts of interest:

Research funding from Predisurge, Biotronik, WL Gore, GE Healthcare 
Honoraria from Abbott, BD, Bentely, Biotronik, Boston Scientific, Cook, Eclevar Medtech, GE Healthcare, Ivascular, Medtronic, Penumbra, Sensome, Shockwave medical, WL Gore (consulting, medical advisory board, educational course, speaking)

Camil-Cassien Bamdé
Camil-Cassien Bamdé
Hospital: Paris Saint-Joseph, France
Part I - Case presentation

Patient history

85-year-old male patient

Symptomatology

  • Bilateral claudication right limb > left limb (Rutherford 3)

Medical history

  • HTA
  • Peripheral arterial disease

Duplex scan

  • Common iliac arteries stenosis / Right CFA stenosis

CT angiography

CT angiography
 

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Part II - Treatment

Answer to our poll: Endovascular repair by outpatient hospitalization

Strategy

  1. Stenting of the right common femoral artery by cross-over
  2. Puncture of the stented right common femoral artery
  3. Iliac kissing stent
Stenting of the right common femoral artery by cross over
Stenting of the right common femoral artery by cross-over
Stenting of the right common femoral artery by cross over
Puncture of the stented right common femoral artery
Iliac kissing stent
Iliac kissing stent

1 - Stenting of the right common femoral artery by cross-over

Retrograde femoral puncture for cross-over

Retrograde femoral punctureRelative counter-indications

  • Aorto-bifemoral bypass ++
  • Severe aorto-iliac lesions

Advantages

  • X-ray exposure
  • Concomitant endovascular repair
  • Compression

Drawbacks

  • Cross-over procedure
  • Longer catheter
  • Worse pushability
  • Patient misunderstanding
  • Cost

 

Duplex scan-guided puncture to increase the safety and the efficacy of ACD

Duplex scan guided puncture
Duplex scan guided puncture
Angiography
Cross-over with .035 Terumo guidewire, UF 5F catheter & 6F-45 cm Terumo Destination introducer
Intraluminal crossing
Vessel prep with POBA
Primary stenting
Primary stenting

2/ Puncture of the stented right common femoral artery

Stent puncture
6F introducer
Angiography: Iliac bilateral lesions

3 - Iliac kissing stent

Iliac kissing stent
Iliac kissing stent
Final angiography

Take-home messages

  • Duplex-guided puncture is mandatory
  • CFA stenting does not prevent retrograde femoral puncture
Disclosures

Y. Gouëffic reports:

  • Research funding from Abbott, General Electric, Veryan, WL Gore
  • Personal fees and grants from Abbott, Bard, Biotronik, Boston Scientic, Cook, General Electric, Medtronic, Penumbra, Terumo, Veryan, WL Gore (medical advisory board, educational course, speaking)