Native Superficial Femoral Artery Peripheral Atherectomy Site Pseudoaneurysm: A Case Report

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Native Superficial Femoral Artery Peripheral
Atherectomy Site Pseudoaneurysm A Case Report
Shivprasad D. Nikam, MD 18th May 2007

• Shivprasad D. Nikam, MD, Joe H. Morgan, MD, Emad
  M. Zakhary, MD, Spencer W. Galt, MD, James R.
  Elmore, MD, David P. Franklin, MD.
• Geisinger Medical Center, Danville, PA, USA.

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Presentation

• 45 year old female
• Smoker 30 Pack-year history.
• Complaints Bluish discoloration of left great
  toe with burning pain.
• Physical Examination
• dusky discoloration of the great toe
• Palpable pedal pulses

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Intervention

• Atherectomy SilverHawkTM Atherectomy catheter
  (LS Cutter), contra-lateral femoral approach
• Embolic protection device placed in the popliteal
  artery
• Multiple passes of the catheter

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Intimal irregularities
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Post op course

• DVT (Femoral vein of thigh) treated with
  fractionated Heparin and Warfarin.
• SFA progressively aneurysmal
• At 4 months 2.8cm pseudoaneurysm over 8 cm length
  of SFA.

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Treatment

• Placement of 7mm X 10 cm and 7mm X 5 cm covered
  stents.
• Successful exclusion of the pseudoaneurysm

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Clinical course

• 6 weeks In-stent stenosis of the covered stent
• Treated successfully with balloon angioplasty
• Warfarin stopped as DVT treatment was completed
  (Aspirin and Plavix)

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• 1 week Sudden onset left forefoot rest pain with
  dusky discoloration
• Angiography Occluded covered stent

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Intervention

• Mechanical Thrombectomy
• Placement of self expanding nitinol stents within
  the previous covered stent.

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Follow up

• 1 month and 4 month visit
• ABI 1.0
• Duplex widely patent stents.

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Atherectomy Complications

• Talon registry
• Dissection (3.6)
• Perforation (0.8)
• Rare, distal embolism, thrombosis, abrupt
  closure, re-occlusions.
• Earlier atherectomy devices Complications 0 to
  6.5

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Atherectomy site Pseudoaneurysm

• Coronary Circulation
• Histology Media 67, Adventitia 27
• Pseudoaneurysms rare
• Peripheral Circulation
• Vein Grafts One pseudoaneurysm reported
• Native arteries No previously reported
  pseudoaneurysm
• Histology Media 21, Adventitia 1

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Atherectomy site Pseudoaneurysm

• Coronary Circulation
• Histology Media 67, Adventitia 27
• Pseudoaneurysms rare
• Peripheral Circulation
• Vein Grafts One pseudoaneurysm reported
• Native arteries No previously reported
  pseudoaneurysm.
• Histology Media 21, Adventitia 1

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Proposed Mechanical Factors

• Tortuous nature of the vessel
• Oversized atherectomy device
• Lesions close to previous surgical scarring
• Lesions near side branches.

? Role of deeper cuts at the junction of mobile
and immobile segments
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Conclusion

• Long term patency of many endovascular procedures
  is yet to be established.
• Endovascular Surgeons must
• Recognize these risks
• Arrange appropriate follow up
• Plan bail-out procedures.

Thank you !