Direct puncture of the prosthetic bypass graft in the treatment of critical limb ischemia patient undergoing prior axillo-femoral bypass

Balloon valvuloplasty and transcatheter aortic valve replacement via aortofemoral bypass grafts: A case report and review of literature

BACKGROUND

Transcatheter aortic valve replacement (TAVR) can be performed through multiple access sites with the preferred approach being transfemoral. In patients with severe peripheral arterial disease and previous grafts, the safety of transfemoral access via direct graft puncture, especially when performed twice within a short period, remains unclear compared to alternative access methods. We present a case demonstrating the safety and efficacy of direct graft puncture for transfemoral access during balloon aortic valvuloplasty (BAV) and TAVR.

CASE SUMMARY

An 82-year-old man presented with dyspnea on exertion. Echocardiogram was significant for severe aortic stenosis. Following a heart team discussion, the patient was scheduled for a balloon valvuloplasty followed by staged TAVR. Based on pre-TAVR computed tomography angiogram, the aortobifemoral graft was deemed as an appropriate access site. Micropuncture needle was used to access the right femoral artery graft, and the sheath was upscaled to 10 Fr. He underwent successful intervention to ostial left anterior descending and left circumflex arteries, and BAV with 22 mm Vida BAV balloon. Hemostasis was achieved using Perclose. For TAVR, an 8 Fr sheath was inserted via the right femoral bypass graft. The arteriotomy was pre-closed with two Perclose ProGlides and access was upsized to 18F Gore DrySeal. A 5Fr sheath was used for left femoral bypass graft access. Patient underwent successful TAVR with 29 mm CoreValve. Hemostasis was successfully achieved using 2 Perclose for right access site and one Perclose for left side with no postoperative bleeding complications.

CONCLUSION

BAV and TAVR are feasible and safe through a direct puncture of the aortofemoral bypass graft with successful hemostasis using Perclose.

Successful case of direct puncture of a prosthetic bypass graft in endovascular treatment for long superficial artery chronic total occlusion: a case report

Background

The access site for endovascular therapy (EVT) is often limited because of multi-vascular diseases. Prior lower limb bypass can potentially limit the availability of common femoral artery access when EVT is required.

Case summary

An 88-year-old woman who presented with non-healing ulceration in the dorsalis pedis of the left foot despite treatment for several months was admitted to our hospital. She had undergone axillo-bilateral femoral bypass surgery for right critical limb ischaemia 3 years previously. Ultrasound and contrast computed tomography demonstrated bypass graft occlusion, left superficial femoral artery (SFA)-popliteal artery long chronic total occlusion from the origin with severe calcification and severe stenosis in the bilateral common femoral artery close to the anastomotic site. EVT for the left SFA occlusion was necessary to save the left foot, but access sites for EVT were limited. We decided to puncture an occluded axillo-femoral prosthetic bypass graft. It is difficult to cross the wire with only an antegrade approach. Therefore, it was necessary to use a bi-directional approach with dorsalis pedis artery puncture and the Rendez-vous technique. Finally, angiogram demonstrated improved blood flow to the wound site, and haemostasis at the puncture site could be achieved by manual compression. The ulceration healed within a month.

Discussion

Direct puncture of a prosthetic bypass graft and additional techniques resulted in complete revascularization. Thus, direct puncture of a bypass graft could be a useful EVT strategy for patients with complex and extremely long chronic total occlusion.