Patient Presentation

A woman in her mid 60s with a past medical history of coronary artery disease, type 2 diabetes mellitus, and peripheral artery disease with previous left superficial femoral artery (SFA) stenting presented to the outpatient clinic with progressive life-limiting claudication (Rutherford class 3/4). Outpatient workup including ankle-brachial index (ABI) and arterial ultrasound revealed an ABI of 0.35 and an occluded SFA stent with reconstitution at the popliteal level. The patient failed medical therapy and walking exercise; due to progression to Rutherford class 4, peripheral angiography was performed.

Ultrasound-guided right radial artery access was achieved using a short 5/6-F Glidesheath Slender® (Terumo Interventional Systems). The aortic arch was navigated using a 5-F, 125-cm JR4 catheter, which was advanced to the left external iliac artery (EIA), where a selective angiogram was obtained. Angiography revealed an occluded SFA from the ostium, as well as reconstitution at the adductor canal (Figure 1).

Figure 1. Diagnostic angiograms showing the long chronic total occlusion in the SFA, with in-stent restenosis that reconstituted at the distal SFA with single-vessel runoff.

Procedural Overview

Using a long, stiff Hi-Torque Supra Core guidewire (Abbott), a long 6-F, 119-cm R2P® Destination Slender® sheath (Terumo Interventional Systems) was advanced to the left EIA. The lesion was navigated by a 200-cm R2P® NaviCross® microcatheter (Terumo Interventional Systems) and an 0.018-inch Glidewire® Advantage® (Terumo Interventional Systems), which was swapped with a 475-cm ViperWire (Abbott) upon crossing the distal cap. Laser atherectomy using a 1.5-mm Auryon XL laser (AngioDynamics) was performed, with excellent results (Figure 2). Next, balloon angioplasty was performed using a 5- X 100-mm R2P® Crosstella® balloon (Terumo Interventional Systems), followed by 3-minute inflation of a 5- X 150-mm In.Pact Admiral drug-coated balloon (DCB). The final angiogram revealed 0% residual stenosis, with single-vessel runoff.

Figure 2. Laser atherectomy using a 1.5-mm Auryon laser followed by balloon percutaneous transluminal angioplasty using the 5- X 100-mm R2P® Crosstella® balloon (A) followed by inflation of a 5- X 150-mm In.Pact Admiral DCB (B). Final angiography showed 0% residual stenosis, with a patent SFA and popliteal artery, single-vessel runoff, and no complications (dissection or distal embolization) (C-E).

Sameh Sayfo, MD, MBA, FSCAI, FACC
Program Director, Endovascular Fellowship Program
PERT Program Director
Baylor Scott & White The Heart Hospital
Plano, Texas
sameh.sayfo@bswhealth.org
Disclosures: Receives research grant from Terumo; consultant to Terumo, Boston Scientific Corporation, Cordis, Surmodics, AngioDynamics, and Medtronic.