willnat2
Networker
I am having trouble with this procedure. Please help...
PROCEDURE PERFORMED:
1. Angiography of the left lower extremity including the fem-popliteal bypass, popliteal, posterior tibial, and profunda.
2. Aspiration of the fem-pop with heel into the posterior tibial artery.
3. Thrombolysis of the femoral popliteal bypass as well as the posterior tibial and popliteal.
4. PTCA of the fem-popliteal anastomosis and PTCA of the mid posterior tibial.
COMPLICATIONS: None
INDICATIONS: An 83 year old patient , who had developed occlusion of the fem-popliteal bypass over the past 10 days with significant disabling left lower extremity claudication. The patient received TPA for 24 hours overnight intra arterially at the site of the proximal femoral popliteal bypass in order to assist with revascularization of the lower extremities.
Thank you for your help.
Leslie
METHODS: The patient was brought to the special procedure room in stable condition. O2 sat, heart rate, blood pressure monitoring were done. A 1% lidocaine was used for anesthetic to the right leg and a 6 French crossover sheath that was in place was exchanged out in sterile fashion with 7 French Cook crossover catheter.
Angiography was then performed. We then required multiple balloons, wires, and infusion catheters in order to reestablish flow in the left lower extremity.
At the end of the case, we left the sheath in place with the infusion catheter in place through which to continue with TPA drip fore residual layered thrombus. Overall, the patient tolerated the procedure well.
ANGIOGRAPHY RESULTS: Angiography of the left lower extremity revealed patency of the profunda.
The fem-popliteal bypass was still totally occluded in its proximal aspect. although there was a small blush feeling located in the proximal aspect after the TPA infusion. The posterior tibials reconstituted distally through collateralization.
INTERVENTION: We then ran through the 7 French crossover sheath were able to place a 5 French Glidewire, which easily went down through the graft down into the posterior tibial artery. We then used an 0.035 Glidewire, which easily went down through the graft down into the posterior tibial artery. We then dilated suing a 4 x 100 balloon at the site of known stenosis at the popliteal anastomotic site. We dilated for 3.5 to 4 minutes at 6 to 8 atmospheres.
We still had occlusion of the vessel at that time, but some minimal amount of flow seen. We then used a 6 French multipurpose catheter and did aspiration throughout the length of the fem-popliteal bypass. We then switched out to a 6 French multipurpose guide catheter with a large luminal opening and proceeded to aspirate the entire length of the vessel, improving the overall flow. At that point, we then placed an infusion catheter from its distal end on the proximal posterior tibial and small proximal end of the fem-popliteal bypass and infused 2 mg of TPA over approximately 20 minutes. This also existed in flow at the site. We then exchanged down to on 0.014 Graphix wire, which we placed into the distal posterior tibial, over which we placed a 2.5 x 40 balloon and dialted to high-grade stenosis of 90% seen in the posterior tibial. The results of that were excellent with improvement again inflow. We then aspirated additional time in the mid portion of the fem-popliteal bypass, removing a significant amount debriding clot. At that point, we had flow down to the foot. It was TIMI grade 1 to 2 with some layered thrombus still present. We therefore elected to place the infusion catheter back into the graft through the 7 French crossover sheath. We then started infusion of 0.5 mg of TPA per hour to be infused overnight along with intravenous heparin.
IMPRESSION: Successful revascularization of the fem-popliteal bypass graft in the left lower extremity requiring aspiration as well as thrombolysis and percutaneous transluminal coronary angioplasty of the anastomotic site, which had know a 90 % lesion taken down to less than 10% as well as a know mid posterior tibial artery stenosis of 90% taken down to less than 10%.
RECOMMENDATIONS: Recommend that we leave the infusion catheter in the graft overnight and infuse 0.5 mg of TPA per hour overnight with heparin. Remove catheters tomorrow late morning and at that point, we will watch the patient closely over the weekend with repeat angiogram on Monday in order to assess patency of the vessel.
PROCEDURE PERFORMED:
1. Angiography of the left lower extremity including the fem-popliteal bypass, popliteal, posterior tibial, and profunda.
2. Aspiration of the fem-pop with heel into the posterior tibial artery.
3. Thrombolysis of the femoral popliteal bypass as well as the posterior tibial and popliteal.
4. PTCA of the fem-popliteal anastomosis and PTCA of the mid posterior tibial.
COMPLICATIONS: None
INDICATIONS: An 83 year old patient , who had developed occlusion of the fem-popliteal bypass over the past 10 days with significant disabling left lower extremity claudication. The patient received TPA for 24 hours overnight intra arterially at the site of the proximal femoral popliteal bypass in order to assist with revascularization of the lower extremities.
Thank you for your help.
Leslie
METHODS: The patient was brought to the special procedure room in stable condition. O2 sat, heart rate, blood pressure monitoring were done. A 1% lidocaine was used for anesthetic to the right leg and a 6 French crossover sheath that was in place was exchanged out in sterile fashion with 7 French Cook crossover catheter.
Angiography was then performed. We then required multiple balloons, wires, and infusion catheters in order to reestablish flow in the left lower extremity.
At the end of the case, we left the sheath in place with the infusion catheter in place through which to continue with TPA drip fore residual layered thrombus. Overall, the patient tolerated the procedure well.
ANGIOGRAPHY RESULTS: Angiography of the left lower extremity revealed patency of the profunda.
The fem-popliteal bypass was still totally occluded in its proximal aspect. although there was a small blush feeling located in the proximal aspect after the TPA infusion. The posterior tibials reconstituted distally through collateralization.
INTERVENTION: We then ran through the 7 French crossover sheath were able to place a 5 French Glidewire, which easily went down through the graft down into the posterior tibial artery. We then used an 0.035 Glidewire, which easily went down through the graft down into the posterior tibial artery. We then dilated suing a 4 x 100 balloon at the site of known stenosis at the popliteal anastomotic site. We dilated for 3.5 to 4 minutes at 6 to 8 atmospheres.
We still had occlusion of the vessel at that time, but some minimal amount of flow seen. We then used a 6 French multipurpose catheter and did aspiration throughout the length of the fem-popliteal bypass. We then switched out to a 6 French multipurpose guide catheter with a large luminal opening and proceeded to aspirate the entire length of the vessel, improving the overall flow. At that point, we then placed an infusion catheter from its distal end on the proximal posterior tibial and small proximal end of the fem-popliteal bypass and infused 2 mg of TPA over approximately 20 minutes. This also existed in flow at the site. We then exchanged down to on 0.014 Graphix wire, which we placed into the distal posterior tibial, over which we placed a 2.5 x 40 balloon and dialted to high-grade stenosis of 90% seen in the posterior tibial. The results of that were excellent with improvement again inflow. We then aspirated additional time in the mid portion of the fem-popliteal bypass, removing a significant amount debriding clot. At that point, we had flow down to the foot. It was TIMI grade 1 to 2 with some layered thrombus still present. We therefore elected to place the infusion catheter back into the graft through the 7 French crossover sheath. We then started infusion of 0.5 mg of TPA per hour to be infused overnight along with intravenous heparin.
IMPRESSION: Successful revascularization of the fem-popliteal bypass graft in the left lower extremity requiring aspiration as well as thrombolysis and percutaneous transluminal coronary angioplasty of the anastomotic site, which had know a 90 % lesion taken down to less than 10% as well as a know mid posterior tibial artery stenosis of 90% taken down to less than 10%.
RECOMMENDATIONS: Recommend that we leave the infusion catheter in the graft overnight and infuse 0.5 mg of TPA per hour overnight with heparin. Remove catheters tomorrow late morning and at that point, we will watch the patient closely over the weekend with repeat angiogram on Monday in order to assess patency of the vessel.