Fig. 19.7 Left popliteal arteriogram

Question 8

What’s your next move?

A.  Call for a laser which is the only device that can cross a lesion of this length

B.  Initiate long term catheter directed thrombolytic therapy and transfer to the Surgical Intensive Care Unit (SICU)

C.  Using a soft tip wire, with back up stiffness, gently pass the wire through the chronic occlusion

D.  Mechanical thrombolysis with a jet spray of tissue plasminogen activator E.  Mechanical thrombectomy with a rotating tip device

The wire passes and is securely “parked” in the infrapopliteal segment. There appears to be a small amount of extravasation of contrast originating from the occluded segment that was crossed (Fig. 19.9).

Fig. 19.8 Left distal femoral artery arteriogram

Fig. 19.9 Left distal femoral artery arteriogram

Question 9

What is your next move?

A.  Immediately convert to open operation because of the extravasation

B.  Deploy a bare metal stent across the occluded segment and balloon angioplasty it C.  Deploy a covered stent across the occluded segment and balloon angioplasty it D.  Use coil embolization to control the bleeding that might occur later that night E.  B or C

You successfully deploy a covered stent across the lesion and follow up with balloon angioplasty and completion images (Figs. 19.10–19.12). A pulse is now palpable behind the knee and there is a faintly palpated pulse in the foot and excellent Doppler derived arterial signal.

Fig. 19.10 Left femoral arteriogram

Fig. 19.13  Post reconstruction lower extremity segemental arteruial pressures

Fig. 19.14  Lower extremity segmental arterial presures when patient returned acutely symptomatic