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Paper text:
peripheral artery disease ( pad ) is a significant medical problem , particularly among the elderly population1 - 3 ) because it is associated with a significantly elevated risk of cardiovascular disease morbidity and mortality.2 ) elderly patients who undergo surgical intervention have higher post operative mortality.4)5 ) hence , percutaneous transluminal angioplasty ( pta ) has become an accepted alternative to bypass surgery in patients with pad.1 ) however , determining the appropriate access strategy for peripheral vascular interventions often requires a much greater degree of planning and foresight than with cardiac catheterization .
occasionally , pta through a bypass graft is required to improve inflow or run - off vessels as well as to treat graft stenosis or occlusions as an alternative treatment option to reoperation in patients at high surgical risk .
we report a case in which we successfully performed pta of contralateral inflow iliac artery and superficial femoral artery via femorofemoral bypass graft in a pad patient .
a 73-year - old male with a long - standing left common iliac artery occlusion underwent femorofemoral crossover grafting 4 years ago .
in addition , he had angioplasty and stenting of the right superficial femoral artery on different occasions within the previous year at other hospitals .
the patient reported mild improvement in claudication symptoms for a few months only after each of these procedures .
he had a past medical history of hypertension and diabetes in addition to a 60 pack - year history of smoking .
for the past two months , the patient complained of claudication in both lower legs as well as severe pain in the right lower leg at rest ( rutherford category 4 ) . on physical examination
ankle brachial indices indicated a score of 0.34 on the right and 0.60 on the left .
computerized tomography angiography revealed a patent graft , but it also showed a high - grade focal stenosis of the right common iliac artery and a total occlusion of the superficial femoral artery ( fig .
arterial access was obtained in the left common femoral artery below the level of femorofemoral crossover graft .
angiography showed that the right common iliac artery had severe stenosis of a focal 80% lesion ( fig .
a 5 fr glide catheter ( terumo , tokyo , japan ) and a 0.035 inch radiofocus angled soft guide 263 cm wire ( terumo , tokyo , japan ) crossed the stenosis of the right common iliac artery via femorofemoral crossover graft .
then , the stenosis was predilated using a 7.080.0 mm balloon catheter ( powerflex ; cordis , miami , fl , usa ) at 10 atm for 120 seconds .
in addition , 8.0100 mm self expandable stent ( smart , cordis , miami , fl , usa ) was deployed in the right common iliac artery .
after stent placement , control angiogram showed no significant residual stenosis or dissection ( fig .
3 ) . using a 0.035 inch straight terumo wire with a backup catheter ( 5 fr multipurpose catheter ; cordis , miami , fl , usa ) , successful wiring of the superficial femoral artery was performed by intraluminal wire passage without significant dissection .
total occlusion was dilated using a 5.080.0 mm balloon catheter ( powerflex ; cordis , miami , fl , usa ) at 10 atm for 120 seconds and 7.080 mm balloon catheter ( powerflex ; cordis , miami , fl , usa ) at 6 atm for 120 seconds .
this resulted in no significant residual stenosis or dissection through the superficial femoral artery ( fig .
the patient had no residual symptoms ( rutherford category 0 ) ; the right ankle - brachial index improved from 0.34 to 0.83 and the left ankle - brachial index improved from 0.60 to 0.88 .
percutaneous transluminal angioplasty is an alternative revascularization technique for pad . because stenting is less invasive compared to endarterectomy or bypass graft , advanced - age patients or patients at high surgical risk are more likely to be candidates for pta .
typically , interventions at the iliac artery level are performed either in a retrograde approach after puncture of the ipsilateral femoral artery or in a crossover technique by obtaining arterial access on the contralateral side of the lesion , and subsequently maneuvering the guide wire across the aortic bifurcation into the diseased vessel .
the choice of approach varies between institutions and for individual patients . due to the fact that the number of patients who have undergone reconstructive vascular surgery is continuously increasing , we are faced with an increasing demand for peripheral artery revascularization in patients with bypass graft . for those patients ,
the traditional approach has been employed through a transradial approach or the brachial artery in order to avoid direct puncture of the graft site due to possible postprocedural complications.6)7 ) however , this approach requires special effort in the optimization of the backup and the stabilization of the guiding catheter .
this procedure often requires a good strategy , appropriate catheter manipulations and the use of specific technical maneuvers .
sometimes , given its distance from the radial artery and the brachial artery , the femoral artery stenosis may not be reached using this approach .
we would like to recommend the convenience of the procedure over pta via graft vessel .
because larger devices are required for iliac artery and femoral artery stenosis compared to coronary intervention , it is convenient to use the backup and the stabilization of the guiding catheter , and also easy to manipulate the use of specific technical maneuvers , such as wire and catheter . in this case , it was possible to salvage a successful outcome that would only have been possible with pta of contralateral inflow iliac artery and superficial femoral artery via femorofemoral bypass graft in a patient of pad .
peripheral arterial disease represents a significant problem , particularly among the elderly population . 
 there has been great progress made in the treatment of peripheral arterial disease in recent years . 
 percutaneous transluminal angioplasty ( pta ) has been employed as a method of treatment for patients with a variety of peripheral arterial disease . 
 we report our experience with pta of contralateral common iliac and superficial femoral arteries via graft vessel in a patient with femorofemoral bypass due to ipsilateral iliac artery occlusion .