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Case presentation: Critical Limb Ischemia

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

  2. 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

  3. Diagnostic angiographic images

  4. Diagnostic angiographic images

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

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

  7. Primary crossing with Viance catheter Right lateral view

  8. (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

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

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

  11. 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

  12. 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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