Cath Lab Digest - November 2007 - (Page 9)

NOVEMBER 2007 CUTTING-EDGE CASES 9 continued from page 1 DRUG-ELUTING STENT SOLUTIONS Multi-Disciplinary Approach Case Report: Critical Limb Ischemia A 50-year-old female with past medical history of hypertension, diabetes mellitus, transient ischemic attack, hypercholesterolemia and morbid obesity was seen in the clinic. She presented with right second toe osteomyelitits following nail clipping. She had no wound healing for three months despite continuous antibiotic therapy and maximal medical treatment. Critical limb ischemia, Rutherford category V with a right ankle brachial index (ABI) of 0.63 was documented. Physical examination of the right lower extremity demonstrated a palpable femoral pulse with no palpable popliteal, posterior tibial and dorsalis pedis arterial pulses. A baseline lower extremity angiogram was performed. This demonstrated the bilateral common iliac artery, external iliac artery and common femoral arteries to have only mild luminal irregularities without any hemodynamically significant stenosis. The right lower extremity runoff showed a Transatlantic Inter-Society Consensus (TASC) D, distal superficial femoral artery (SFA) occlusion. Reconstitution of the proximal popliteal artery via collaterals and one vessel run off via the anterior tibial artery to dorsalis pedis artery was noted. A contralateral approach (“cross over technique”) from the left common femoral artery was not successful because the lesion could not be crossed successfully into the distal popliteal artery. The case was presented at the weekly multi-disciplinary vascular conference and an antegrade approach with a femoral artery cut down was discussed. A femoral-popliteal (fem-pop) bypass was not considered as the initial option due the co-morbidities of morbid obesity, hypertension and diabetes mellitus. An ipsilateral antegrade approach is common for such a procedure. However, in a morbidly obese patient, the antegrade approach carries a high risk for vascular access complications of hemorrhage, hematoma, pseudoaneurysm, and/or infection. The popliteal approach to access under ultrasound guidance is also an excellent acceptable option. Once again, placing a morbidly obese patient in the prone position can be cumbersome for the patient and in this case, access to the popliteal artery would result in a very short working length from the puncture site. The dorsalis pedis can be accessed percutaneously; however, it limits the size of the sheath that can be placed and also risks vessel dissection or hematoma that can have deleterious sequelae. After discussion of all options, a vascular cut down and access of the dorsalis pedis artery was planned. The procedure was performed in the cardiac catheterization laboratory utilizing local anesthesia and conscious sedation. The dorsal aspect of the right foot was prepared and draped in a sterile fashion. The dorsalis pedis artery was identified using a sterile continuous wave 10MHz Doppler probe. A small cut down incision was performed by a vascular surgeon for direct visualization to micro puncture the artery. The vascular surgeon also assisted during the angioplasty of the superficial femoral artery. A 5 French 10-cm length flexor sheath was introduced over a wire. A 4 French glide catheter (Terumo Medical Corp., Somerset, NJ) and 0.035-inch stiff angled Terumo straight wires were used to cross the occluded distal SFA. The wire was changed to a 0.035-inch angle soft Terumo wire to successfully cannulate the distal SFA into the mid SFA. The recannulation was confirmed by catheter injection and the 0.035-inch wire was exchanged for a 0.018-inch V18 control wire (Boston Scientific, Natick, MA). Initial balloon angioplasty was performed with 4 x 100 mm Savvy balloon (Cordis Corp., Miami Lakes, FL) followed by 5 x 100 mm Sterling balloon (Boston Scientific). Final angiogram showed a patent distal SFA with < 30% residual stenosis (Figure 2). The wire and sheath were removed and the cut down site was sutured successfully with 7-0 prolene. A palpable pulse was Improving Patient Compliance with Antiplatelet Medications This monthly column in Cath Lab Digest reviews important points of distinction in drug-eluting stents, from characteristics to techniques, to provide valuable and relevant information about this technology. By Larry S. Dean, MD Dr. Larry S. Dean is a Professor of Medicine and Surgery at the University of Washington School of Medicine and Director of the University of Washington Regional Heart Center at the University of Washington Academic Medical Center. He served his internship and residency at the University of Washington School of Medicine. He received his cardiology training, including interventional cardiology, at the University of Alabama School of Medicine and he then joined the faculty at the University of Alabama in 1986. Dr. Dean served as Assistant Chief of Staff of University of Alabama Hospital and was also Director of the Cardiac Catheterization Laboratory and Professor of Medicine. He returned to Seattle in 2000. Dr. Dean is board-certified in internal medicine, cardiovascular disease and interventional cardiology. He has been involved and widely published in interventional cardiovascular techniques for more than 20 years. Q A At this year’s Transcatheter Cardiovascular Therapeutics (TCT) meeting, the Stentplus™ Patient Success Program was introduced. What is the intent of this program? The objective of the Stentplus Program is to improve patient compliance with dual antiplatelet therapy following implantation of a drug-eluting stent (DES). One of the key components of the program is that all patients are eligible to receive the program benefits, regardless of the type of DES they receive. I believe this program will be tremendously beneficial to patients in supporting adherence to antiplatelet medications. Why is antiplatelet therapy following DES implantation so important? Several studies have reinforced the importance of patient compliance with antiplatelet therapies after DES implantation. For example, a study by Antonio Colombo showed that premature discontinuation of antiplatelet medication after DES placement is a predictor of stent thrombosis (Figure 1), so we knew some time ago that antiplatelet therapy was continued on next page Q A Figure 1. Incidence, Predictors, and Outcome of Thrombosis after Successful Implantation of Drug-Eluting Stents. Iakovou et al., JAMA 2005;293:2126–2130. Figure 1. Surgical cut down for dorsalis pedis access.

Table of Contents Feed for the Digital Edition of Cath Lab Digest - November 2007

Henry Ford Heart and Vascular Institute Treating Patients with Complex Vascular Disease with a Multi-Disciplinary Approach Improving Patient Compliance with Antiplatelet Medications Clinical Editor’s Corner Cath Lab Nurse/Tech Vascular Access and Closure Using the StarClose® Device The Clinical and Economic Impact of Measuring Fractional Flow Reserve FFR and Choosing an Optimal Revascularization Strategy Finally! The New Registered Cardiac Electrophysiology Specialist (RCES) Credential Use of a Mobile Lab to ‘Test the Waters’ at a Rural Hospital Remembering a Cardiac Cath Lab History ACVP• Membership Page What Do You Think? The Ten-Minute Interview with… Ernie Livingston, RN, BSN SICP* Chapter Updates Who’s in Charge? Working to Eliminate Bottlenecks: Florida Hospital’s Cardiac Cath Lab Achieves Greater Efficiency and Higher Satisfaction Preserving Left Ventricular Function during Percutaneous Coronary Intervention Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Making the Most of Your First Impression: Interviewing Tips and Techniques CEU Education Center Clinical & Industry News Meetings Calendar

Cath Lab Digest - November 2007

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