Case presentation critical limb ischemia
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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

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Case presentation: Critical Limb Ischemia

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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


Diagnostic angiographic images


Initial unsuccessful attempt

Contralateral CFA access

6F Crossover sheath

Primary GW/support

catheter crossing

Escalation of symptoms

after failed attempt


Repeat attempt in 4 weeks

Antegrade access with 6F

45 cm sheath


Primary crossing with Viance catheter

Right lateral view


(a)

Viance blunt microdissection catheter

Torque Handle

135 cm shaft (2.3F)

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

6x40mm nSES

Two 3x38mm DES

Significant improvement in patient symptoms at 3m F/U


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