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Below Knee Angioplasty

19/11/2019 -  

Royal Liverpool University Hospital
Liverpool, UK

Operators: Tze Chan

Clinical History:

A 54-year-old diabetic patient presented with an ulcer and osteomyelitis which responded poorly to antibiotics. The ulcer extends from the medial to the plantar surface of the right foot. Ultrasound Doppler of the right lower limb identified a mild popliteal artery stenosis. The below knee vessels were heavily calcified and poorly visualised. We proceeded with an on table angiography and angioplasty.


Risk Factors:

Arterial hypertension, IDDM

Procedure:

Right antegrade CFA access was chosen. The procedure was started with a Terumo Radifocus 0.035" wire supported with a NaviCross® catheter. Diagnostic angiography demonstrated a moderate to severe AT origin stenosis (Fig. 1). The PT and peroneal arteries were patent proximally but taper out into very small vessels in the foot and do not appear to communicate with the plantar arch. Distally, there was a tight stenosis in the distal dorsalis pedis artery (Fig. 2). A long 55cm 6Fr sheath was introduced over a 0.035" Bentson wire and parked at the popliteal artery. The 0.035" wire was exchanged for a 0.018" Terumo advantage wire and a NaviCross® catheter were used to cannulate and cross the proximal AT lesion.


The stenosis was angioplastied with a 3 x 40mm Senri PTA balloon catheter with good results (Fig. 3). The DP was seen to supply the plantar arch and it was felt that the patient may benefit from angioplasty of the DP lesion to improve supply to the plantar arch. This was treated with a 2x40mm Terumo Senri PTA balloon catheter with significant recoil. Further balloon angioplasty performed with a 2.5x40mm PTA catheter yielded satisfactory results (Fig. 4).


Conclusion:

The NaviCross® catheter with the 30o angled tip is a useful workhorse catheter to start with a 0.035" system when intervening above the knee and converting to a 0.018" system below the knee.