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Transmural coil embolization — alternative technique for management of arterial perforation during subintimal angioplasty

View Article: PubMed Central - PubMed

ABSTRACT

Subintimal angioplasty of lower limb arterial occlusion carries a relatively higher risk of vessel perforation compared to transluminal angioplasty. Vessel perforation is a potentially life threatening complication which requires prompt recognition and management. They are usually managed by endovascular techniques such as low-pressure balloon tamponade, covered stents, and coil embolization of the ruptured artery. We describe a technique of treating vessel perforation following balloon angioplasty. Patient developed a large perforation of the proximal superficial femoral artery (SFA) after balloon inflation during subintimal angioplasty of complete SFA occlusion. Following failure of balloon tamponade in sealing the perforation, we successfully treated it by deploying an embolization coil at the site of perforation through the vessel wall followed by balloon tamponade. Our technique could be a useful relatively inexpensive alternative treatment option in the management of vessel perforation compared to covered stents.

No MeSH data available.


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(A, B) Proximal superficial femoral artery perforation with brisk extravasation. (C) Shows the tip of Bernstein catheter at the site of perforation. (D) Shows balloon tamponade post coil deployment at site of perforation
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Figure 3: (A, B) Proximal superficial femoral artery perforation with brisk extravasation. (C) Shows the tip of Bernstein catheter at the site of perforation. (D) Shows balloon tamponade post coil deployment at site of perforation

Mentions: An antegrade left transfemoral angiogram demonstrated a complete left superficial femoral artery (SFA) occlusion from its origin with diffuse arterial wall calcification. The popliteal artery was noted to reconstitute via collaterals from the profunda and a good three vessel runoff in the calf was present [Figure 1A–D]. 3000 international units (IU) of heparin was given intra-arterially at the beginning of the procedure as per our standard local protocol. Initial attempts to cross the occlusion via transluminal approach were unsuccessful probably due to the chronic calcific occlusion extending from the SFA origin. The SFA occlusion was crossed via antegrade subintimal approach using a 035ʺ hydrophilic wire (Terumo, Japan) supported by a 5F Bern™ catheter (Cordis, USA). Successful re-entry into the true lumen of the proximal popliteal artery was confirmed with contrast injection. Our standard practice is to attempt crossing of the lesion preferably via an antegrade approach as the first option before moving on to a retrograde approach. Angioplasty was performed using a 5 mm × 4 cm balloon (Admiral Xtreme™—MEDTRONIC, USA). Initial post-angioplasty run showed significant residual stenoses and a small distal SFA perforation. This perforation was successfully treated using the 5 mm balloon inflated intraluminally at the level of the perforation for 120 s [Figure 2]. The residual stenoses were treated with a 6 mm × 4 cm shaft balloon (Admiral Xtreme™—MEDTRONIC, USA), following which a large perforation was noted in the proximal SFA [Figure 3A and B], which could not be resolved by low-pressure balloon tamponade despite prolonged balloon inflation up to 5 min. The balloon catheter was exchanged for a 4 Fr Bernstein catheter over a 035ʺ guide wire and positioned with its tip through the perforation [Figure 3C]. Using this catheter, a 5 mm × 50 mm (MReye™ Embolization coil—COOK Medical, USA) coil was deployed at the site of the perforation, which was pushed through the vessel wall, to just outside the adventitia. Following this, the 6 mm balloon was inflated at low pressure for a few seconds at this site [Figure 3C and D] to reduce the chance of coil migration and aid the sealing of the perforation. Final angiogram showed patent SFA with no leak and brisk distal runoff [Figure 4].


Transmural coil embolization — alternative technique for management of arterial perforation during subintimal angioplasty
(A, B) Proximal superficial femoral artery perforation with brisk extravasation. (C) Shows the tip of Bernstein catheter at the site of perforation. (D) Shows balloon tamponade post coil deployment at site of perforation
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5036335&req=5

Figure 3: (A, B) Proximal superficial femoral artery perforation with brisk extravasation. (C) Shows the tip of Bernstein catheter at the site of perforation. (D) Shows balloon tamponade post coil deployment at site of perforation
Mentions: An antegrade left transfemoral angiogram demonstrated a complete left superficial femoral artery (SFA) occlusion from its origin with diffuse arterial wall calcification. The popliteal artery was noted to reconstitute via collaterals from the profunda and a good three vessel runoff in the calf was present [Figure 1A–D]. 3000 international units (IU) of heparin was given intra-arterially at the beginning of the procedure as per our standard local protocol. Initial attempts to cross the occlusion via transluminal approach were unsuccessful probably due to the chronic calcific occlusion extending from the SFA origin. The SFA occlusion was crossed via antegrade subintimal approach using a 035ʺ hydrophilic wire (Terumo, Japan) supported by a 5F Bern™ catheter (Cordis, USA). Successful re-entry into the true lumen of the proximal popliteal artery was confirmed with contrast injection. Our standard practice is to attempt crossing of the lesion preferably via an antegrade approach as the first option before moving on to a retrograde approach. Angioplasty was performed using a 5 mm × 4 cm balloon (Admiral Xtreme™—MEDTRONIC, USA). Initial post-angioplasty run showed significant residual stenoses and a small distal SFA perforation. This perforation was successfully treated using the 5 mm balloon inflated intraluminally at the level of the perforation for 120 s [Figure 2]. The residual stenoses were treated with a 6 mm × 4 cm shaft balloon (Admiral Xtreme™—MEDTRONIC, USA), following which a large perforation was noted in the proximal SFA [Figure 3A and B], which could not be resolved by low-pressure balloon tamponade despite prolonged balloon inflation up to 5 min. The balloon catheter was exchanged for a 4 Fr Bernstein catheter over a 035ʺ guide wire and positioned with its tip through the perforation [Figure 3C]. Using this catheter, a 5 mm × 50 mm (MReye™ Embolization coil—COOK Medical, USA) coil was deployed at the site of the perforation, which was pushed through the vessel wall, to just outside the adventitia. Following this, the 6 mm balloon was inflated at low pressure for a few seconds at this site [Figure 3C and D] to reduce the chance of coil migration and aid the sealing of the perforation. Final angiogram showed patent SFA with no leak and brisk distal runoff [Figure 4].

View Article: PubMed Central - PubMed

ABSTRACT

Subintimal angioplasty of lower limb arterial occlusion carries a relatively higher risk of vessel perforation compared to transluminal angioplasty. Vessel perforation is a potentially life threatening complication which requires prompt recognition and management. They are usually managed by endovascular techniques such as low-pressure balloon tamponade, covered stents, and coil embolization of the ruptured artery. We describe a technique of treating vessel perforation following balloon angioplasty. Patient developed a large perforation of the proximal superficial femoral artery (SFA) after balloon inflation during subintimal angioplasty of complete SFA occlusion. Following failure of balloon tamponade in sealing the perforation, we successfully treated it by deploying an embolization coil at the site of perforation through the vessel wall followed by balloon tamponade. Our technique could be a useful relatively inexpensive alternative treatment option in the management of vessel perforation compared to covered stents.

No MeSH data available.


Related in: MedlinePlus