case_images: PMC10684329_01
case_images: The diagnostic angiography. (a) Red arrow indicates the ostium of the occluded FPB. Blue arrow indicates the ostium of the occluded DFA. (b) Blood flow was observed in the proximal part of the PA via the collateral vessels. A floating thrombus was observed in the proximal part of the PA (white arrow). The middle part of the PA and PTA was occluded (dotted line). (c) Blood flow in the plantar artery through the collateral vessels was observed. DFA: deep femoral artery; FPB: femoropopliteal bypass; PA: popliteal artery; PTA: posterior tibial artery.
case_images: CRIVAM2023-6730220.001.jpg
case_images: PMC10684329_01_CRIVAM2023-6730220.001.jpg
case_images: fig1
case_images: ABI was 1.1, which was within the normal value. A diagnostic angiography of the left lower extremities showed total occlusion of the native SFA, FPB, and ostium at the left deep femoral artery (DFA) (Figure 1(a)). In addition, the angiography revealed a floating thrombus in the proximal popliteal artery (PA) and occlusion from the middle PA to the posterior tibial artery (PTA) (Figure 1(b)). The distal PTA, plantar artery, and peroneal artery were detected via collateral circulation (Figure 1(c)).
case_images: (a) A Fogarty catheter was used to remove the thrombus in the graft. (b) DCB angioplasty using a 4 x 80 mm IN.PACT Admiral was performed on the popliteal artery. (c) DCB angioplasty using a 5 x 40 mm IN.PACT Admiral was performed on the distal anastomosis. DCB angioplasty using a 6 x 80 mm IN.PACT Admiral was performed on the proximal anastomosis. DCB: drug-coated balloon.
case_images: CRIVAM2023-6730220.002.jpg
case_images: PMC10684329_01_CRIVAM2023-6730220.002.jpg
case_images: fig2
case_images: We performed a Fogarty catheter thrombectomy (Edwards Lifesciences, Irvine, CA, USA) and removed the thrombus from the occluded FPB and proximal PA (Figure 2(a)). IN.PACT Admiral (Medtronic) (Figure 2(b)). In addition, we performed DCB angioplasty for proximal anastomosis with a 6 x 80 mm IN.PACT Admiral (Medtronic) and distal anastomosis with a 5 x 40 mm IN.PACT Admiral (Medtronic) after plain balloon angioplasty with a 5 x 40 mm JADE (OrbusNeich) (Figure 2(c)).
case_images: Angiograms immediately after therapy (a-e). (f) IVUS findings immediately after treatment of the proximal anastomosis. Moderate stenosis due to isoechoic plaque (yellow arrow) was noted. IVUS: intravascular ultrasound.
case_images: CRIVAM2023-6730220.003.jpg
case_images: PMC10684329_01_CRIVAM2023-6730220.003.jpg
case_images: fig3
case_images: The final angiography showed residual stenosis at the proximal anastomosis, and good blood flow was observed (Figures 3(a)-3(e)). ST (Philips, Amsterdam, Netherlands) showed residual stenosis at the proximal anastomosis with isoechoic plaque and drug-applied findings (Figure 3(f)). Subsequently, prasugrel (3.75 mg/day) and rivaroxaban (10 mg/day) were administered.
case_images: QVA of follow-up angiographies. (a) QVA of immediately after treatment. (b) QVA of 6 months after treatment. (c) QVA of 18 months after treatment. (d-g) Follow-up angiographies 18 months after treatment. QVA: quantitative vessel angiography analysis.
case_images: CRIVAM2023-6730220.004.jpg
case_images: PMC10684329_01_CRIVAM2023-6730220.004.jpg
case_images: fig4
case_images: In quantitative vessel angiography analysis (QVA) for residual stenosis of the proximal anastomosis, the stenosis rates immediately after EVT, at 6 months, and at 18 months were 61%, 51%, and 15%, respectively (Figures 4(a)-4(c)). Lower extremity angiography 18 months after EVT showed good blood flow in the FPB, PA, and PTA (Figures 4(d)-4(g)).