Sample Interventional Challenging Cases

Title: 2 CC OF CONTRAST: A CASE OF INTRAVASCULAR ULTRASOUND ASSISTED ENDOVASCULAR AORTIC REPAIR

Authors: Antoine Addoumieh, Shamim M. Badruddin, Srikanth Damaraju, University of Texas Health Science Center, Houston, TX, USA

Patient Initials or Identifier Number: RQ

Relevant History and Physical Exam: 55-year-old male with history of hypertension, dyslipidemia, abdominal aortic aneurysm (AAA), adult polycystic kidney disease (APKD) with stage IV chronic kidney disease.

Relevant Test Results Prior to Catheterization: CT abdomen and pelvis without contrast showed presence of APKD, AAA measuring 5.5 x 5.4 cm, an increase of 0.9 cm over 1 year. Baseline laboratory work showed BUN 36, creatinine of 3.2 with eGFR of 21 significantly limiting the ability to use contrast. Due to rapidly enlarging AAA, the patient was scheduled for Intravascular ultrasound (IVUS) guided endovascular abdominal aneurysm repair (EVAR).

Relevant Catheterization Findings: None

Interventional Management: Patient was planned for IVUS guided EVAR. An ultrasound guided access of the right common femoral artery (CFA) was obtained using 4F micropuncture kit and position of catheter was confirmed angiographically using 1 cc of contrast. Sheath was upsized to 6F, "Preclosed" using Perclose ProGlide then vessel was serially dilated up to 18 F. Access of the left CFA was obtained similarly and position was confirmed using 1 cc of contrast. Sheath was upsized to 6 F and site was "Preclosed", then a 12 F sheath was introduced. A 0.035" Glidewire was advanced through the 18 F sheath beyond the aneurysm. IVUS was used to identify and precisely mark the location of bilateral renal arteries, measure the size of the aneurysm, and estimate the takeoff of iliac arteries. The main body of the Gore 36 mm device was introduced through the 18 F sheath, and IVUS was advanced through the 12 F sheath to confirm location of renal arteries. The main body of the stent graft was deployed and a 4 F Omniflush was advanced through it and used to engage bilateral renal arteries confirming infrarenal deployment of the stent. The contralateral limb was then introduced through the 12 F sheath and was deployed successfully. Final IVUS images were obtained confirming the infrarenal deployment of stent graft with excellent apposition. Location of stent grafts in both iliac arteries was also confirmed. No further angiography was preformed due to patient's renal dysfunction. Total contrast used was 2 cc.

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Title: POST CORONARY ARTERY BYPASS SURGERY CHRONIC TOTAL OCCLUSION REQUIRING TRIPLE ACCESS AND ROTABLATION OF DONOR VESSEL

Authors: Shane Parfrey, Leeds General Infirmary, Leeds, United Kingdom

Patient Initials or Identifier Number: PW

Relevant History and Physical Exam: A 74-year-old man was electively admitted for percutaneous coronary intervention (PCI) of left circumflex chronic total occlusion (CTO) due to ongoing effort angina on three anti-anginal agents. He had a history of coronary artery bypass surgery (CABG) 1991: Left internal mammary artery (LIMA) to left anterior descending (LAD), saphenous vein graft (SVG) to posterior descending artery (PDA) and saphenous vein graft to obtuse marginal (OM).

Relevant Test Results Prior to Catheterization: Echocardiography showed mild left ventricular systolic dysfunction.

Relevant Catheterization Findings: Angiogram showed a patent LIMA-LAD, patent SVG-PDA with moderate- severe disease, native circumflex CTO with occluded graft. A potential collateral channel arising from a severely disease diagonal was identified to the obtuse marginal.

Interventional Management: With biradial 7 French access, the diagonal was wired with a Fielder XTA, however a 1.0mm balloon would not. Rotational atherectomy with 1.25mm burr was performed, improving access to the collateral. Retrograde crossing was performed with a SUOH 3 guidewire and a Caravel 150cm microcatheter. Ping-pong guides were taken for guideliner facilitated reverse controlled antegrade and retrograde tracking (CART). Antegrade balloon assisted sub-intimal entry (BASE) was performed with a 2.0mm balloon and a Gladius guidewire. An RG3 guidewire was externalized. Femoral access provided a third access point, required to visualize the distal circumflex via the LIMA. A dual lumen Twin Pass microcatheter tip injection facilitated wiring of the SVG retrogradely and of the OM. Following pre-dilatation, stenting of the circumflex and diagonal to ostium LAD was performed followed by crush stenting in the left main. Intra-vascular ultrasound (IVUS) guided kissing balloon inflation was performed, with excellent final result. Complex problem solving may be required in the post CABG CTO patient, including triple access and Rotablation of the donor vessel.

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