A 69-year-old female patient with a long vascular history, presented with acute critical limb ischemia of the left extremity after stopping her anticoagulation.
She had received an aortobifemoral graft at the age of 53, and had two prior episodes with acute occlusion of the right limb of the graft, 10 and 14 years after the primary operation. Both occlusions was resolved with catheter-directed thrombolysis, the last time with application of a stent in the proximal part of the right limb of the graft.
CTA confirmed thrombosis of the left leg of the aortic-bifemoral bypass, and new short occlusions of two calf arteries. There was also wall thrombus in the native aorta above the graft, as well as in the main body of the graft.
After discussion with the vascular surgeon, we started catheter-based intraluminal tPA-administration via a crossover hook-shaped catheter, with the intention to aspirate residual emboli from the calf the next day if needed.
After 12 hours, the thrombus was dissolved. There was significant residual stenosis due to neointimal hyperplasia or wall adherent thrombus in the proximal limb, and the ipsilateral groin was punctured to apply kissing stents at the bifurcation of the graft (Fig. 1a and b). Control angiograms after stent placement showed restricted flow through the ipsilateral limb, with correct placement of the wire in the aorta above the graft anastomosis (Fig. 2a and b). The findings of the angiograms were consistent with neointimal dissection at two levels. At the proximal level, the stent was deployed inside the false lumen, with the distal end inside the true lumen. The proximal neointimal dissection could only be resolved with prolonging the kissing stents all the way to the proximal graft anastomosis (Fig. 3). The distal dissection was not flow limiting after the wire was moved to the correct lumen via buddy wire technique, and this dissection was left untreated.
Emboli to the ipsilateral calf were aspirated, but completion angiograms showed some residual thrombi and a chronical occlusion of the dorsal pedal artery.
The patient is back to her habitual state 6 months after the procedure, with no rest pain or wounds, but some claudication at 500 m. The patient was anticoagulated with double platelet inhibition, but started with apixaban from the cardiologist due to atrial flutter. She is currently instated on life-long anticoagulation with apixaban and ASA.