Occluded Right SFA

Physician: David E. Cohen, MD
Cardiology Associates
West Paterson, NJ

Relevant history and physical exam: This is a 26-year-old male complaining of severe claudication of the right calf that limited him to about 20 yards of ambulation. The patient first developed right calf claudication 5 years ago and underwent a right femoropopliteal bypass. The graft closed one week later and did not respond to thrombolytic therapy. A second femoropopliteal bypass procedure was performed but this bypass also failed two weeks after surgery.

His family history is moderately positive for cardiovascular disease. The patient's HDL-cholesterol was 15 mg/dL. There is no history of trauma and he has three siblings who are healthy. He is an ex-smoker.

Angiography performed at the time of his bypasses showed an occluded right SFA reconstituted at the popliteal artery below the adductor canal. ABI at that time was 0.60, dropping to 0.36 with exercise.

Relevant test results prior to catheterization: On physical examination, the right femoral, popliteal, and pedal pulses were not palpable, although the right femoral pulse was detected with Doppler. Left pulses were normal. There was no sign of critical limb ischemia.

Relevant catheterization findings: Diagnostic angiography of the right leg was performed from a contralateral left femoral artery approach. The right common and internal iliac arteries were patent. There was a flush occlusion of the right external iliac artery, complete nonvisualization of the common femoral artery (CFA) and the right superficial femoral artery (SFA) (Image 1). The popliteal artery was reconstituted about 4 cm above the knee joint (Image 2). The "isolated" right profunda femoral artery was filling from collaterals originating in the pelvic area (Image 3).

Interventional management: With a guidewire and 5-French Glidecath (Terumo, Somerset, New Jersey) fed over the aortic bifurcation from the left femoral access, a 7-French sheath was advanced into the right common iliac artery. Attempts to probe with different hydrophilic guidewires into the right external iliac flush occlusion were unsuccessful. A Frontrunner 3900 CTO catheter (LuMend, Redwood City, CA) was used to penetrate the cap of the occlusion and advanced readily into the right external iliac artery and then through the common femoral and into the profunda. Contrast was then injected to confirm intraluminal position in the profunda artery.

After switching to a 0.014" guidewire via the Frontrunner exchange catheter, the SilverHawk Plaque Excision Catheter SV1 (FoxHollow Technologies, Redwood, CA) was advanced through the occluded external iliac, and common femoral arteries and about 6 cutting runs made. Afterwards, a larger SilverHawk Peripheral Catheter LV1 was employed (Image 4) and several more cutting passes were made, excising a total of 104.3 mg of fibrotic tissue (Image 5). Angiography then showed a marked improvement in the caliber of the external iliac and common femoral arteries, with good flow into the profunda artery. The right femoral pulse was now strongly palpable. Balloon angioplasty with a 6 mm x 10 cm balloon was performed but caused the patient severe pain on inflation, even with high doses of morphine. Maximum attainable pressure was 6 atmospheres.

Attention was now turned to the right SFA occlusion. Attempts to advance a guidewire from the CFA into the SFA were unsuccessful as there was no visible stump, so the patient's femoral sheath was sutured into place and the patient was then placed into the prone position and the right popliteal fossa anesthetized. The right popliteal artery was punctured using a Doppler needle and fluoroscopic guidance. The retrograde popliteal puncture was performed at the level of the knee joint in order to obtain adequate access distal to the level of popliteal reconstitution, which was only 4 cm above the knee joint. A 4-French micropuncture sheath was inserted into the popliteal and, with some manipulation, a 0.035" Glidewire was successfully advanced up into the SFA, then allowing for exchange to a 5-French sheath.

Through this sheath, a 5-French Glide catheter was placed for support over the Glidewire, and this assembly was advanced retrograde into the SFA and easily entered the common femoral artery. Using contrast to ensure position, the wire was then changed to a 0.014" wire and the SilverHawk device was again used from the popliteal access to make several plaque-excising passes through the popliteal and superficial femoral arteries (Image 6). An additional 36.8 mg of plaque were removed (Image 7). Angiography showed a 4 mm lumen throughout the entire length of the previously occluded SFA and popliteal artery. Balloon angioplasty was performed with a 5 mm x 10 cm balloon at 6 atmospheres, again causing severe pain with inflation.

The concluding angiogram (click to view figure 8) showed an excellent result: patent right external iliac, common femoral, superficial femoral, and popliteal arteries. The right pedal pulses were palpable following the procedure.

The right popliteal and left femoral artery sheaths were carefully removed using manual compression. The patient was discharged home the next day on Plavix 75 mg once daily, aspirin 325 mg daily, and niacin 100 mg daily to be titrated up to 1000 mg or the highest tolerated dose.

Three months later the patient remained completely asymptomatic.