The femoral bifurcation does not tolerate endovascular miscalculation

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The patient presented with complaints of leg and foot pain with sitting and short distance calf claudication, being unable to walk more than 100 feet. This is unusual because sitting usually relieves ischemic rest pain. He is in late middle age and developed claudication a year prior to presentation that was treated with stent grafting of his superficial femoral artery from its origin to Hunter’s canal at his local hospital. This relieved his claudication only briefly, but when the pain recurred a few months after treatment, it was far worse than what he had originally. Now, when he sat at his desk, his foot would go numb very quickly and he would have to lie down to relieve his pain.

On examination, the patient was moderately obese with overhanging belly. He had a palpable right femoral pulse, but nothing below was palpable. He had multiphasic signals in the dorsalis pedis and posterior tibial arteries. The left leg had a normal arterial exam. Pulse volume recording and segmental pressures were measured:

preop PVR2

These are taken with the patient lying down which was the position that relieved his pain, and the PVR’s show some diminishment of inflow. It would be easy at this point to declare the patient’s pain to be due to neuropathy or spinal stenosis, but because of his inability to walk more than a hundred feet and because of his severe pain with sitting, I went ahead and obtained a CTA.

3DVR

The CTA showed he had an occluded superficial femoral artery (SFA) with patent profunda femoral artery (PFA) with reconstitution of an above knee popliteal artery with multivessel runoff. The 3DVR image showed his inguinal crease to be right over the femoral bifurcation which is not an unsual finding, but his stent graft was partially occluding his profunda femoral artery.

CTA centerline

I decided to take him to the operating room to relieve his PFA of this obstruction. My plan was to remove the stent graft at the origin of the SFA and at the same time, remove the plaque and occluded stent graft from his SFA to restore it to patency.

In the OR, on exposing his SFA, I discovered that because of his overhanging belly, his inguinal ligament had sagged and was compressing his femoral bifurcation.

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This explained his presentation. The stent graft really had no chance as when he sat, the belly and ligament compressed it at the origin, and because it partially occluded the origin of the PFA, sitting probably pinched off flow completely. The 3dVR image shows the mid segment of PFA to have little contrast density -this is not because of thrombus, but because of the obstruction, the PFA was getting collateral flow from the hypogastric artery.

The stent graft was removed at its origin via a longitudinal arteriotomy after remote endarterectomy of the distal graft.

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In this case, the Multitool (LeMaitre) was useful in dissecting the plaque and stent graft because of its relatively stiff shaft compared to the standard Vollmer rings. The technique of EndoRE has been described in prior posts (link).

procedure picture

The stent graft came out in a single segment -they come out easier than bare stents.

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post angio compositeThe patient regained palpable pulses in his right foot and recovered well, being discharged home after a 4 day stay.

While one could argue that just taking out the short piece of occlusive stent graft over the PFA was all that was necessary, I feel that there is no added harm in sending down a dissector around the stent, and in this patient there was restoration of his SFA patency which was the intent of the original procedure.

Unlike PTFE bypasses that sometimes fail with thromboembolism, SFA EndoRE fails with development of focal stenoses. From a conversation I had with Dr. Frans Moll at the VEITH meeting, I found that he has had good experience with using drug coated balloons in the treatment of these recurrent stenoses.

At the time of discharge, the patient was relieved of his rest pain, and was no longer claudicating. The common femoral artery, its bifurcation, and the profunda femoral artery remain resistent to attempts at endovascular treatment, and remain in the domain of open surgery. And in retrospect, the history and physical examination had all the clues to the eventual answer to the oddities of the patient’s complaints. The combination of inguinal crease, abdominal pannus, and low hanging inguinal ligament meant these structures acted to crush the stent graft and femoral bifurcation.

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