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Management of acute lower extremity thrombosis associated with bilateral popliteal aneurysms using combined thrombolytic therapy and stent graft repair.

Guo BL, Fu WG, Shi ZY, Wang LX, Guo DQ - Chin. Med. J. (2015)

View Article: PubMed Central - PubMed

Affiliation: Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Institute of Vascular Surgery, Shanghai 200032, China.

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To the Editor: This is a brief clinical report on different endovascular procedures in the treatment of popliteal artery aneurysms (PAAs)... Duplex ultrasound was performed and an embolization (Rutherford Grade 2b) and bilateral PAAs were found, which on computed tomography angiogram (CTA) measured 62 mm and 82 mm with the maximum diameters in the right and left popliteal artery, respectively... Thrombus was found in both aneurysm sacs [Figure 1a and b]... Then, we treated the bilateral PAAs with different stent grafts under endovascular procedures... Multiple stent grafts were overlapped by at least 2 cm... The diameter of the stent graft was oversized by 15% compared with the caliber of the anchorage... After angiography for the right PAA, intraoperative intravascular ultrasound indicated that the diameters of the distal and the proximal landing zones were 7.7 mm and 7.5 mm, respectively... Follow-up results at 6 months after the last procedure were satisfactory [Figure 1k and l]... The patient was not symptomatic, and reduction of vigorous exercises was recommended... In contrast, the patency rate with the EE in the same case was not good enough, with ISR, stent fracture, and thrombosis noted during follow-up... Although two bare stents were positioned in the proximal and distal landing zones to improve the flexibility of the EE and to prevent its migration, this strategy also increased the friction at the junction of the two stents, which may lead to stent fracture and ISR because of the “lever-arm effect. ” However, the VSG may can better adapt to the tortuous femoropopliteal vessels and resist the continuous mechanical stresses observed in this region... ISR and in-stent re-thrombosis remain the major complications of infrainguinal stenting, resulting in low stent patency... The best medical treatment for individuals, including antiplatelet and anticoagulation therapy, is indispensable and is of great interest and concern after endovascular procedures.

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Computed tomography angiogram (CTA) showed bilateral popliteal artery aneurysms (PPAs) with a two-vessel run-off peripherally (a) and thrombus within the aneurysm sacs (b). The postprocedure angiography highlighted the results after stent placement with Excluder Extension (EE) stent grafts and two bare stents (c). Digital subtraction angiography showed the knee flexion angiography after stent placement with Viabahn stent grafts (d). CTA at 6 months showed 100% patency of the stent grafts, aneurysm exclusion, and three-vessel run-off peripherally (e and g). The X-ray showed a restenosis in the proximal region of the EE (arrows, f) and stent fracture in the distal bare stent (arrow, h). Postoperative CTA showed acute thrombosis in the left popliteal artery and below the knee. The vessels in the right lower extremity still retained patent (i). After thrombolytic therapy, the popliteal, anterior tibial, and posterior tibial arteries were almost patency (j). During the following-up, the EE involved thrombosis in the middle of the graft, but the Viabahn was without (k and l).
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Figure 1: Computed tomography angiogram (CTA) showed bilateral popliteal artery aneurysms (PPAs) with a two-vessel run-off peripherally (a) and thrombus within the aneurysm sacs (b). The postprocedure angiography highlighted the results after stent placement with Excluder Extension (EE) stent grafts and two bare stents (c). Digital subtraction angiography showed the knee flexion angiography after stent placement with Viabahn stent grafts (d). CTA at 6 months showed 100% patency of the stent grafts, aneurysm exclusion, and three-vessel run-off peripherally (e and g). The X-ray showed a restenosis in the proximal region of the EE (arrows, f) and stent fracture in the distal bare stent (arrow, h). Postoperative CTA showed acute thrombosis in the left popliteal artery and below the knee. The vessels in the right lower extremity still retained patent (i). After thrombolytic therapy, the popliteal, anterior tibial, and posterior tibial arteries were almost patency (j). During the following-up, the EE involved thrombosis in the middle of the graft, but the Viabahn was without (k and l).

Mentions: A 75-year-old man presented at the vascular clinic with progressive left lower limb pain at rest associated with coolness, pain, and paresthesia. His medical history was significant for hypertension and hyperlipidemia. The femoral and popliteal pulsations were only felt in the left limb. Coldness, pallor, paresthesia, delayed capillary refilling, and color changes were noted in the left limb together with rest pain. Duplex ultrasound was performed and an embolization (Rutherford Grade 2b) and bilateral PAAs were found, which on computed tomography angiogram (CTA) measured 62 mm and 82 mm with the maximum diameters in the right and left popliteal artery, respectively. Thrombus was found in both aneurysm sacs [Figure 1a and b]. Thromboembolism from the left PAA could be seen in the distal arteries. Other potentially associated aneurysms were excluded by magnetic resonance angiography. The erythrocyte sedimentation rate and C-reactive protein were moderately elevated, and thrombophilia profile was negative, and history for any orogenital ulcers was negative.


Management of acute lower extremity thrombosis associated with bilateral popliteal aneurysms using combined thrombolytic therapy and stent graft repair.

Guo BL, Fu WG, Shi ZY, Wang LX, Guo DQ - Chin. Med. J. (2015)

Computed tomography angiogram (CTA) showed bilateral popliteal artery aneurysms (PPAs) with a two-vessel run-off peripherally (a) and thrombus within the aneurysm sacs (b). The postprocedure angiography highlighted the results after stent placement with Excluder Extension (EE) stent grafts and two bare stents (c). Digital subtraction angiography showed the knee flexion angiography after stent placement with Viabahn stent grafts (d). CTA at 6 months showed 100% patency of the stent grafts, aneurysm exclusion, and three-vessel run-off peripherally (e and g). The X-ray showed a restenosis in the proximal region of the EE (arrows, f) and stent fracture in the distal bare stent (arrow, h). Postoperative CTA showed acute thrombosis in the left popliteal artery and below the knee. The vessels in the right lower extremity still retained patent (i). After thrombolytic therapy, the popliteal, anterior tibial, and posterior tibial arteries were almost patency (j). During the following-up, the EE involved thrombosis in the middle of the graft, but the Viabahn was without (k and l).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4836267&req=5

Figure 1: Computed tomography angiogram (CTA) showed bilateral popliteal artery aneurysms (PPAs) with a two-vessel run-off peripherally (a) and thrombus within the aneurysm sacs (b). The postprocedure angiography highlighted the results after stent placement with Excluder Extension (EE) stent grafts and two bare stents (c). Digital subtraction angiography showed the knee flexion angiography after stent placement with Viabahn stent grafts (d). CTA at 6 months showed 100% patency of the stent grafts, aneurysm exclusion, and three-vessel run-off peripherally (e and g). The X-ray showed a restenosis in the proximal region of the EE (arrows, f) and stent fracture in the distal bare stent (arrow, h). Postoperative CTA showed acute thrombosis in the left popliteal artery and below the knee. The vessels in the right lower extremity still retained patent (i). After thrombolytic therapy, the popliteal, anterior tibial, and posterior tibial arteries were almost patency (j). During the following-up, the EE involved thrombosis in the middle of the graft, but the Viabahn was without (k and l).
Mentions: A 75-year-old man presented at the vascular clinic with progressive left lower limb pain at rest associated with coolness, pain, and paresthesia. His medical history was significant for hypertension and hyperlipidemia. The femoral and popliteal pulsations were only felt in the left limb. Coldness, pallor, paresthesia, delayed capillary refilling, and color changes were noted in the left limb together with rest pain. Duplex ultrasound was performed and an embolization (Rutherford Grade 2b) and bilateral PAAs were found, which on computed tomography angiogram (CTA) measured 62 mm and 82 mm with the maximum diameters in the right and left popliteal artery, respectively. Thrombus was found in both aneurysm sacs [Figure 1a and b]. Thromboembolism from the left PAA could be seen in the distal arteries. Other potentially associated aneurysms were excluded by magnetic resonance angiography. The erythrocyte sedimentation rate and C-reactive protein were moderately elevated, and thrombophilia profile was negative, and history for any orogenital ulcers was negative.

View Article: PubMed Central - PubMed

Affiliation: Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Institute of Vascular Surgery, Shanghai 200032, China.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

To the Editor: This is a brief clinical report on different endovascular procedures in the treatment of popliteal artery aneurysms (PAAs)... Duplex ultrasound was performed and an embolization (Rutherford Grade 2b) and bilateral PAAs were found, which on computed tomography angiogram (CTA) measured 62 mm and 82 mm with the maximum diameters in the right and left popliteal artery, respectively... Thrombus was found in both aneurysm sacs [Figure 1a and b]... Then, we treated the bilateral PAAs with different stent grafts under endovascular procedures... Multiple stent grafts were overlapped by at least 2 cm... The diameter of the stent graft was oversized by 15% compared with the caliber of the anchorage... After angiography for the right PAA, intraoperative intravascular ultrasound indicated that the diameters of the distal and the proximal landing zones were 7.7 mm and 7.5 mm, respectively... Follow-up results at 6 months after the last procedure were satisfactory [Figure 1k and l]... The patient was not symptomatic, and reduction of vigorous exercises was recommended... In contrast, the patency rate with the EE in the same case was not good enough, with ISR, stent fracture, and thrombosis noted during follow-up... Although two bare stents were positioned in the proximal and distal landing zones to improve the flexibility of the EE and to prevent its migration, this strategy also increased the friction at the junction of the two stents, which may lead to stent fracture and ISR because of the “lever-arm effect. ” However, the VSG may can better adapt to the tortuous femoropopliteal vessels and resist the continuous mechanical stresses observed in this region... ISR and in-stent re-thrombosis remain the major complications of infrainguinal stenting, resulting in low stent patency... The best medical treatment for individuals, including antiplatelet and anticoagulation therapy, is indispensable and is of great interest and concern after endovascular procedures.

Show MeSH
Related in: MedlinePlus