ASSISTANT:
ANESTHESIOLOGIST:
PROCEDURE:
1.
Angiography.
2.
Surgical induction of needle and catheter into right
common femoral artery at approximately 1155 hours.
3.
Non-selective catheter placement, proximal abdominal
aorta with a pigtail catheter at 1201 hours.
4.
Angiography of arterial system, abdominal aortogram,
digital subtraction angiogram, AP projection, at 1202
hours.
5.
Pelvic angiogram after pulling the catheter down to
the distal abdominal aorta, RAO projection, at 1203 hours.
6.
Pelvic angiogram, LAO projection, at 1204 hours.
7.
Bilateral lower extremity runoff with multiple
overlapping stamps by injection into the distal abdominal
aorta at 1205 to 1211 hours.
INTRAVENOUS PROCEDURES:
None.
ENDOVASCULAR SURGERY:
Transcatheter therapy/endovascular surgery, closure of
arteriogram, right common femoral artery, at 1230 hours.
ANESTHESIA: Conscious sedation and local sedation.
DURATION OF PROCEDURE:
One hour.
INDICATION FOR PROCEDURE: Bilateral lower extremity
claudication. The patient has diabetes. Ankle-brachial
indices have been normal; however, due to severe diffuse
calcification and diabetes, that may be erroneous, as was
discussed initially with the patient. This procedure is
being done for further evaluation of the patient's
condition and possible treatment.
TECHNIQUE: The patient was prepped and draped in the usual
sterile fashion over both groin areas. The area of the
right common femoral artery was anesthetized with 1%
lidocaine solution without epinephrine in the subcutaneous
and subcuticular tissues.
A small skin incision was made with a #11 blade. Tissue
was separated with a hemostat. Access was gained to the
right common femoral artery with the use of a single
puncture needle and over a Bentson wire a 6-French arterial
sheath was placed. A pigtail catheter was placed through
the sheath over a Bentson wire and placed in the proximal
abdominal aorta.
Abdominal aortogram was performed in AP projection.
Abdominal aortogram was reviewed. The catheter was pulled
down to the distal abdominal aorta and pelvic angiogram was
performed in bilateral oblique projections.
Lower extremity runoff was done with multiple overlapping
stamps to the level of the ankles.
The catheter was removed. The right common femoral
arterial puncture site was closed with use of 6-French
Angio-Seal device. The patient tolerated the procedure
well.
SPECIMENS TO PATHOLOGY:
None.
FINDINGS: Abdominal aortogram demonstrates mild
irregularity. The mesenteric vessels are visible.
Scattered areas of focal atherosclerosis including an 80%
stenosis in the mid to distal left splenic artery and
scattered areas of moderate narrowing in the hepatic and
SMA arteries are seen. The renal arteries appear
proximally patent.
Pelvic angiogram demonstrates unremarkable common and
external iliac vessels. Internal iliac arteries
demonstrate multifocal moderate disease in the second and
third order branches. The patient denies significant
impotence problems.
Right lower extremity runoff demonstrates moderate areas of
narrowing in the profunda femoral artery. SFA is widely
patent. Multifocal mild areas of narrowing in the
popliteal artery are seen. The runoff is via a single
vessel, which is the anterior tibial artery. The peroneal
artery and posterior tibial arteries are occluded. Few
areas of moderate disease in the proximal anterior tibial
artery are seen. Reconstitution of the distal posterior
tibial artery is noted at the ankle. Surgical clips are
suggestive of previous greater saphenous vein harvestation.
Left lower extremity runoff demonstrates unremarkable
profunda femoral artery and proximal SFA. A few focal
areas of mild narrowing in the distal SFA and the adductor
canal are seen. Popliteal artery also demonstrates mild
areas of multifocal disease. Anterior tibial artery is the
only runoff vessel. Tibioperoneal trunk has multifocal
areas of moderate, severe disease. Posterior tibial artery
and peroneal arteries occlude proximally.
Tibioperoneal trunk angioplasty was contemplated and
discussed with the patient in detail. The patient reports
to be able to walk approximately one mile prior to
significant pain. I would favor not intervening on this
vessel at this time since the patient only has a one-vessel
runoff and dissection or occlusion of this vessel could
prove significant for the patient. Even the most likeliest
intervention would be successful. As I discussed with the
patient, I would favor having the patient continue his
exercise regimen and intervene if he develops more
disabling claudication, rest pain, or lower extremity
ulcers. He agrees.
IMPRESSION: Abdominal aortogram and bilateral lower
extremity runoff was done. Moderate smaller vessel disease
is noted, especially on the tibioperoneal trunk and
infrapopliteal vessels, as described above. Due to
patient's borderline claudication and relative increased
risk of intervention in these smaller vessels, I favored
not intervening at this time. The patient was instructed
to continue his exercise regimen, and if he develops
disabling claudication or worse symptoms, at that point,
revascularization will be done. He understands and agrees
with plan.
Thank you kindly for allowing me to participate in this
patient's care.