Cardiovasc lntervent Radiol (1990) 12:344-345

CardioVascular and Interventional Radiology �9 Springer-Verlag New York Inc. 1990

Catheter Lysis and Percutaneous Transluminal Angioplasty Below the Knee Via the Popliteal Artery in a Patient with Femoral Artery Obstruction: Technical Note

Juergen Schroeder Department of Diagnostic Radiology, Kre iskrankenhaus , Rendsburg, West Germany

Abstract. Acutely occluded lower leg arteries in a patient with a chronically obstructed superficial femoral artery were successfully treated by catheter lysis and dilatation via the popliteal artery.

Key words: Arteries, transluminal angioplasty--Ar- teries, popliteal--Arteries, peripheral--Angiogra- phy, technology

Percutaneous transluminal angioplasty (PTA) via the popliteal artery has been described only for ob- structions of the femoral artery [I]. In the presence of chronic obstruction of the superficial femoral ar- tery, there is no other way to the lower teg arteries, and the popliteal artery provides antegrade access tbr treatment of acute lower leg ischemia.

Case Report

A 74-year-old man had successful PTA of his right lower leg vessels 2~ years previously. His left superficial femoral artery was known to be completely obstructed, and in his left lower leg only the fibular artery was patent. Moreover , in this fibular ar-- tery, a proximal s tenosis and an occluded segment in the mid portion with a large collateral had been documented earlier.

This patient was admitted to the hospital a few hours after acute onset of ischemia in his left lower leg. Angiography demon- strated an occlusion of the distal popliteal artery and the remain- ing proximal fibular artery (Fig 1). After discussing the problem with the vascular surgeons, informed consent was obtained from the patient for an antegrade popliteal artery approach. He was placed in a prone position on the angiographic table. The popli- teal artery was localized by Doppler ul trasound and punctured under local anesthesia. A 0.035 inch Amplatz extra stiff guide- wire was inserted. A straight 5 F catheter was passed over the

Address reprint requests to: Dr. Juergen Schroeder, Abteilung Roentgendiagnost ik, Kre iskrankenhaus , D 2370 Rendsburg, West Germany

guidewire after advancing the guidewire into the occluded seg- ment. Then, after the guidewire was removed, contrast injection showed a little flow along a filling detect about I cm in length at the bifurcation with the s tump of the anterior tibial artery.

One hundred /xg of nitroglycerine and 51)00 U of heparine were administered intraarterially (the patient was on medication of 10 mg of nifedipine twice a day), and catheter lysis was started with 100,000 U of urokinase over a period of 2 hours.

Repeat angiography showed a high-grade stenosis in the pre- viously occluded region (Fig. 2L 3 cm proximal to the fibular stenosis documented 2~ years previously. There was no longer evidence of clot. Following another administrat ion of 100 ~g of nitroglycerine, a 0.020-inch st i ffguidewire with a flexible gold tip was advanced beyond the s tenoses and a 4.5-F dilatation cathe- ter with a 3 mm balloon was placed across both stenoses. Dilata- tion was pertbrmed twice for about 30 sec.

The follow-up angiography demons t ra ted widening of both s tenoses (Fig. 3). All distal arteries were filled in the same man- ner as they had been 2�89 years earlier. Before removing the cathe- ter, a moderate s tenosis of the distal popliteal artery was also dilated with satisfying result.

After compress ing the puncture site over a period of 15 rain, there was no palpable hema toma in the hollow of the knee, and the patient returned to the ward with a warm lower leg.

One year later, the patient is still s ymp tom free.

Discussion

In patients with a chronically obstructed superficial femoral artery and acute ischemia secondary to oc- clusion of the arteries of the lower leg, catheter lysis and PTA are not possible unless the catheter is in- troduced via the popliteal artery. As far as we know, this approach has not been described before. This first trial of antegrade catheter lysis and PTA via the popliteal artery was without any complica- tion and had an excellent result.

Compared to the puncture in the groin, of course, there are some difficulties in catheterization of the popliteal artery caused by the anatomic situa- tion and a tendency to spasm. The popliteal artery lies rather deeply, surrounded with loose tissue,

J. Schroeder: PTA Below the Knee Via the Popliteal Artery 345

Fig. 1. Chronically obstructed superlicial femoral artery and acutely occluded arteries below the knee.

Fig. 2. After catheter lysis an underlying stenosis is demon- strated.

Fig. 3. Following dilatation. Note the catheter enlry to the popli- teal artery.

o v e r a very s t i f f a n d suff ic ient ly f a r - a d v a n c e d guide- wire. This is pa r t i c u l a r l y t rue for in t roduc ing the d i la ta t ion ca the te r , which has to be of low profi le, and in t roduced wi thou t a shea th .

In o rde r to avo id spasm, the pa t ien t should be med ica t ed with n i fed ip ine or n i t rog lycer ine , and ni- t rog lyce r ine should be a d m i n i s t e r e d in t raa r te r ia l ly [21.

and in the ca se of obs t ruc t i on o f the femora l a r t e ry . it is not pa lpab le . H e n c e , it has to be local ized by u l t rasound or, as sugges ted by T o e n n e s e n and co- worke r s [I] , by con t r a s t in jec t ion into the c o m m o n femoral a r t e ry and f luo roscopy .

C o m p a r e d to the groin and also to the axi l la , there is l i t t le subs t ance for c o m p r e s s i n g the ptmc- Cure site and for manua l ly guid ing the ca the te r . It is adv i sab le , t he re fo re , to a d v a n c e the c a t h e t e r only

References

I. Toennesen KH, Sager P. Karle A. Henriksen L, Joergensen B 11988) Pelcutancous transluminal angioplasty of the st/peril- cial femoral artery by retrograde catheterization via the popli- teal artery. Cardiovasc lntervent Radiol 11:127-131

2. Schwarten DE, Cutliff WB (1988) Arterial occlusive disease below the knee: Treatmem with percutaneous transluminal angioplasty performed with low-profile catheters and steer- able guide wires. Radiology 169:71-74