Percutaneous Transluminal Angioplasty of Contralateral Iliac and Superficial Femoral Arteries via Graft Vessel in a Patient with FemoroFemoral Bypass Graft
A 73-year-old male with a long-standing left common iliac artery occlusion underwent femorofemoral crossover grafting 4 years ago. In addition, he had angioplasty and stenting of the right superficial femoral artery on different occasions within the previous year at other hospitals. The patient reported mild improvement in claudication symptoms for a few months only after each of these procedures.\nHe came to our hospital with a disabling bilateral lower extremity claudication. He had a past medical history of hypertension and diabetes in addition to a 60 pack-year history of smoking. For the past two months, the patient complained of claudication in both lower legs as well as severe pain in the right lower leg at rest (Rutherford category 4). On physical examination, he had a faintly palpable dorsalis pedis pulse in the right foot. Ankle brachial indices indicated a score of 0.34 on the right and 0.60 on the left. Computerized tomography angiography revealed a patent graft, but it also showed a high-grade focal stenosis of the right common iliac artery and a total occlusion of the superficial femoral artery (). Due to patient's refusal to undergo surgical revascularization, endovascular treatment was planned for the extensive iliofemoral occlusive disease.\nArterial access was obtained in the left common femoral artery below the level of femorofemoral crossover graft. Angiography showed that the right common iliac artery had severe stenosis of a focal 80% lesion (), and the right superficial femoral artery had total occlusion (). Right external and internal iliac, common femoral and profunda femoris arteries were patent. Femorofemoral crossover graft was also patent.\nA 5 Fr glide catheter (Terumo, Tokyo, Japan) and a 0.035 inch radiofocus angled soft guide 263 cm wire (Terumo, Tokyo, Japan) crossed the stenosis of the right common iliac artery via femorofemoral crossover graft. Then, the stenosis was predilated using a 7.0×80.0 mm balloon catheter (PowerFlex; Cordis, Miami, FL, USA) at 10 atm for 120 seconds. In addition, 8.0×100 mm self expandable stent (Smart, Cordis, Miami, FL, USA) was deployed in the right common iliac artery. After stent placement, control angiogram showed no significant residual stenosis or dissection (). Using a 0.035 inch straight Terumo wire with a backup catheter (5 Fr multipurpose catheter; Cordis, Miami, FL, USA), successful wiring of the superficial femoral artery was performed by intraluminal wire passage without significant dissection. Total occlusion was dilated using a 5.0×80.0 mm balloon catheter (PowerFlex; Cordis, Miami, FL, USA) at 10 atm for 120 seconds and 7.0×80 mm balloon catheter (PowerFlex; Cordis, Miami, FL, USA) at 6 atm for 120 seconds. This resulted in no significant residual stenosis or dissection through the superficial femoral artery ().\nAfter a successful angioplasty, the patient had no residual symptoms (Rutherford category 0); the right ankle-brachial index improved from 0.34 to 0.83 and the left ankle-brachial index improved from 0.60 to 0.88.