shescka
Contributor
Please I'm not sure about this, any help will be really appreciated
PROCEDURE PERFORMED:
1. Aortoperipheral lower extremity angiogram.
2. AngioDynamics pulse spray infusion catheter placement in the right
femoral-popliteal graft for infusion with thrombolytics therapy for
24 hours.
PROCEDURE INDICATION:
Right leg claudication, pain at rest.
BRIEF HISTORY:
This is a 58-year-old male with a history of hypertension, diabetes,
prior peripheral lower extremity stents for peripheral vascular
disease, status post right femoral-popliteal artery bypass graft
placement in 2013, right third to fifth toe amputations previously,
who presented with complaints of pain starting from his right groin
all the way down to his right foot, for which a workup revealed
evidence of occlusion of the right femoral-popliteal bypass graft,
along with occlusion of the left SFA on ultrasound Doppler, for which
he was referred for an aortoperipheral angiogram with possible
intervention.
DESCRIPTION OF PROCEDURE IN DETAIL:
After informed consent was obtained, both groins were prepped and
draped in a sterile fashion, and under moderate sedation using 5 mL of
2 percent lidocaine, using the Mini Stick, a 4-French MS sheath was
placed in the left femoral artery and angiogram confirmed normal
sheath positioning, after which a 4-French pigtail catheter was
positioned in the infrarenal abdominal aorta, after which
aortoperipheral angiography was obtained using digital subtraction
angiography. Angiograms were obtained from the iliac bifurcations down
to the feet. We then noted occlusion of the right femoral popliteal
bypass graft (thrombotic occlusion), for which we prepared for an
intervention on this vessel. The 4-French sheath was exchanged for a 6-
French 45 cm sheath over a soft-tip (____) wire in the left femoral
artery, after which the 4-French rim catheter was used to redirect the
wire down into the right common femoral artery. The 6-French 45 cm
sheath was advanced over the rim catheter down to the right common
femoral artery. The rim catheter was then exchanged for a 4-French
multipurpose catheter, through which an Amplatz wire was used to cross
into the femoral-popliteal bypass graft in the right thigh. The
multipurpose catheter was then advanced over the Amplatz wire down to
the popliteal artery over a V18 wire. This catheter was then removed
and exchanged over the V18 wire for an AngioDynamics pulse spray
catheter placed in the femoral-popliteal bypass graft down to the
popliteal artery. This catheter was then connected to IV thrombolytic
infusion with alteplase, which will infuse at 2 mg/hour for three
hours, followed by 1 mg per hour for the next 24 hours along with
continuous IV heparin infusion through the 6-French 45 cm sheath at
800 units/hour. The catheter and sheath were secured in place, and the
patient was transferred to the intensive care unit for close
monitoring.
ESTIMATED BLOOD LOSS:
30 mL.
ANGIOGRAPHIC FINDINGS:
1. The right external iliac artery stent is patent. No angiographic
stenosis in the right common femoral artery. The right SFA has
chronic total occlusion at its ostium along with thrombotic
occlusion seen at the ostium of the right femoral-popliteal bypass
graft. The right popliteal artery reconstitutes via collaterals
below the knee, along with three-vessel runoff seen below the knee,
but poor flow in these vessels at the level of the feet.
2. The left external iliac artery stent is patent. The left common
femoral artery has no significant obstruction.
3. The left SFA has ostial chronic total occlusion which reconstitutes
above the left knee along with three-vessel runoff seen in the left
leg down to the feet.
POSTOPERATIVE DIAGNOSIS:
Successful placement of AngioDynamics catheter-directed thrombolysis
of the right femoral-popliteal bypass graft with 24-hour alteplase
infusion along with infusion of heparin through the intra-arterial
sheath.
PLAN OF CARE:
Monitor the patient in intensive care unit with IV nicardipine drip to
keep the patient's systolic blood pressure less than 140, along with
neuro checks in the ICU. Continue the alteplase infusion for 24 hours
along with the intra-arterial heparin.
We will reassess the flow in the right leg with an angiogram tomorrow.
PROCEDURE PERFORMED:
1. Aortoperipheral lower extremity angiogram.
2. AngioDynamics pulse spray infusion catheter placement in the right
femoral-popliteal graft for infusion with thrombolytics therapy for
24 hours.
PROCEDURE INDICATION:
Right leg claudication, pain at rest.
BRIEF HISTORY:
This is a 58-year-old male with a history of hypertension, diabetes,
prior peripheral lower extremity stents for peripheral vascular
disease, status post right femoral-popliteal artery bypass graft
placement in 2013, right third to fifth toe amputations previously,
who presented with complaints of pain starting from his right groin
all the way down to his right foot, for which a workup revealed
evidence of occlusion of the right femoral-popliteal bypass graft,
along with occlusion of the left SFA on ultrasound Doppler, for which
he was referred for an aortoperipheral angiogram with possible
intervention.
DESCRIPTION OF PROCEDURE IN DETAIL:
After informed consent was obtained, both groins were prepped and
draped in a sterile fashion, and under moderate sedation using 5 mL of
2 percent lidocaine, using the Mini Stick, a 4-French MS sheath was
placed in the left femoral artery and angiogram confirmed normal
sheath positioning, after which a 4-French pigtail catheter was
positioned in the infrarenal abdominal aorta, after which
aortoperipheral angiography was obtained using digital subtraction
angiography. Angiograms were obtained from the iliac bifurcations down
to the feet. We then noted occlusion of the right femoral popliteal
bypass graft (thrombotic occlusion), for which we prepared for an
intervention on this vessel. The 4-French sheath was exchanged for a 6-
French 45 cm sheath over a soft-tip (____) wire in the left femoral
artery, after which the 4-French rim catheter was used to redirect the
wire down into the right common femoral artery. The 6-French 45 cm
sheath was advanced over the rim catheter down to the right common
femoral artery. The rim catheter was then exchanged for a 4-French
multipurpose catheter, through which an Amplatz wire was used to cross
into the femoral-popliteal bypass graft in the right thigh. The
multipurpose catheter was then advanced over the Amplatz wire down to
the popliteal artery over a V18 wire. This catheter was then removed
and exchanged over the V18 wire for an AngioDynamics pulse spray
catheter placed in the femoral-popliteal bypass graft down to the
popliteal artery. This catheter was then connected to IV thrombolytic
infusion with alteplase, which will infuse at 2 mg/hour for three
hours, followed by 1 mg per hour for the next 24 hours along with
continuous IV heparin infusion through the 6-French 45 cm sheath at
800 units/hour. The catheter and sheath were secured in place, and the
patient was transferred to the intensive care unit for close
monitoring.
ESTIMATED BLOOD LOSS:
30 mL.
ANGIOGRAPHIC FINDINGS:
1. The right external iliac artery stent is patent. No angiographic
stenosis in the right common femoral artery. The right SFA has
chronic total occlusion at its ostium along with thrombotic
occlusion seen at the ostium of the right femoral-popliteal bypass
graft. The right popliteal artery reconstitutes via collaterals
below the knee, along with three-vessel runoff seen below the knee,
but poor flow in these vessels at the level of the feet.
2. The left external iliac artery stent is patent. The left common
femoral artery has no significant obstruction.
3. The left SFA has ostial chronic total occlusion which reconstitutes
above the left knee along with three-vessel runoff seen in the left
leg down to the feet.
POSTOPERATIVE DIAGNOSIS:
Successful placement of AngioDynamics catheter-directed thrombolysis
of the right femoral-popliteal bypass graft with 24-hour alteplase
infusion along with infusion of heparin through the intra-arterial
sheath.
PLAN OF CARE:
Monitor the patient in intensive care unit with IV nicardipine drip to
keep the patient's systolic blood pressure less than 140, along with
neuro checks in the ICU. Continue the alteplase infusion for 24 hours
along with the intra-arterial heparin.
We will reassess the flow in the right leg with an angiogram tomorrow.
