Strategies on the Frontline Case presentation Critical Limb

Strategies on the Frontline Case presentation: Critical Limb Ischemia Subhash Banerjee, MD VA North Texas Health Care & UT Southwestern Med. Ctr. Dallas, TX

Case presentation • 77 year old diabetic male Veteran with presents with c/o a “deep sensation of pain” in his right calf • Partial relief is often obtained by taking a short walk around the room • Right coronary artery PCI 6 months ago • Continues to smoke cigarettes • ABI: 0. 5 (B/L); ankle pressure 52 mm Hg

Diagnostic angiographic images

Initial unsuccessful attempt Contralateral CFA access 6 F Crossover sheath Primary GW/support catheter crossing Escalation of symptoms after failed attempt

Repeat attempt in 4 weeks Antegrade access with 6 F 45 cm sheath

Primary crossing with Viance catheter Right lateral view

Viance blunt microdissection catheter (a) Torque Handle 135 cm shaft (2. 3 F) 0. 035 OD: compatible with most support catheters 0. 014” guidewire (300 cm) Distal Catheter Tip (rounded, atraumatic, 1 mm) (b) Torque Handle

Subintimal passage and re-entry with Enteer Successful TP trunk re-entry with Enteer catheter & wire Followed by IVUS confirmation

IVUS confirmation of distal true lumen access Sub-intimal space s/p balloon dilation Compressed true lumen atheroma

Enteer re-entry catheter Orienting balloon with radio-opaque markers indicating wire-exit ports on diametrically opposite sides of the balloon Stingray GW with 0. 0035” distal taper

Final result after distal SFA & TP trunk stenting 6 x 40 mm n. SES Two 3 x 38 mm DES Significant improvement in patient symptoms at 3 m F/U