Peripheral

PAD with in-stent restenosis and calcified crossing management

PAD with in-stent restenosis and crossing remains a challenge. Study the case of a 62-year-old patient with coronary disease, obesity, diabetes, and dyslipidemia, who has a history of RCIA, LCIA, and SFA stenting, along with thromboendarterectomy of the RCFA. Presenting with Rutherford III claudication, predominantly on the left side, recent angiography revealed aorto-iliac femoral patency, significant SFA lesions, and popliteal artery thrombosis on the left. Analyze the perioperative angiogram for the left leg and share your insights on the best treatment approach.

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)

Jérôme Brunet
Jérôme Brunet
Avignon, France
Caroline Caradu
Caroline Caradu
Bordeaux, France
Part I - Case presentation

A 62-year-old patient with :

  • Coronary diseases / obesity / diabetic status / dyslipidemia
  • Previous RCIA, LCIA + SFA stenting and thromboendarterectomy of RCFA
  • Clinical worsening status, with Rutherford III on both sides and predominant on left side
  • Recent investigation with Angio CT scan and per operative angiography showing:
    • Aorto-ilio femoral patency associated with important SFA lesions and thrombosis on popliteal artery on left side

Crossover 5Fr 45 Cm, per operative angiogram for the left leg

  • CFA patent, proximal ISR in SFA, further stent patent
  • Very slow flow, mid and distal 1/3 of SFA patent with no ISR or calcified lesions
  • Very slow flow, popliteal lesions with pre thrombotic calcified lesion on P2-P3
  • Very slow flow, multi-lesions on BTK predominant on TTP
  • Very slow flow, ATA and PTA remaining patent till the foot

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Part II - Treatment

Team decision

  • Crossover right to left to treat ISR Proximal 1/3 of SFA: DEB strategy
  • Antegrade puncture to treat distally the calcified popliteal lesion: debulking + DEB strategy
  • Outpatient treatment

 

  • 5 Fr sheath access by crossover
  • ISR crossing with Asahi Gladius 0.018 – 300
  • Predilatation with ABBOTT Armada 5 x 60 during 2 minutes
  • DEB strategy for ISR TOSAKA 2 with Ivascular Luminor 18 6 x 80 during 2.30 minutes
  • Angiogram control: EXCELLENT
  • Often angiogram control at 10 minutes or at the end of the procedure to avoid any fast restenosis after SMC rehydratation
  • From crossover to antegrade treatment 
  • Antegrade puncture
  • In-stent direct puncture
  • 5 Fr thereafter 7 Fr 45 cm sheath
  • 0.035 guidewire
  • 5 Fr sheath
  • Changed for 7 Fr sheath 45 cm
  • Close to popliteal lesion and adapted to next therapeutic strategy
  • Popliteal angiogram showing pre-thrombotic popliteal calcified lesion at P2 level
  • Popliteal calcified lesion crossing
  • Spartacore 0.014
    • ABBOTT Command 0.014
       
  • Large magnification for popliteal angiogram
  • Pre-thrombotic lesion
  • 0.014 guidewire crossing
  • Debulking device for calcified lesion
  • BSCI - Jetstream 2.1 / 3.0
  • 0.014 platform
  • Debulking device
  • BSCI Jetstream 2.1 / 3.0
  • Slow movement / multi-crossing
  • Without or with fins 2.1 / 3.0 mm
  • Angiogram control
  • Debulking technique
  • 3.0 mm (with fins) crossing
  • multi-crossing if required
  • Medication: IV 3 mg Risordan + 2 mg Ispotine
  • Angiogram control
  • Perfect result post-debulking
  • 30 % stenosis remaining
  • DEB therapy after debulking
  • BSCI Ranger 5 x 80 with 3-minute inflation
  • Angiogram control
  • Excellent result
  • Distal control on BTK arteries
  • Excellent control and run-off
  • End of procedure 
  • Double closure with closure device Femoseal©
  • Outpatient procedure