Popliteal artery total occlusion – a challenging therapy approach

Introduction: In patients with peripheral artery disease, the superficial femoral and popliteal arteries are challenging vessels for achieving both initial success and durable patency. The initial success and durability of endovascular therapy in the femoropopliteal artery is limited by the diffuse nature of the disease, presen-ce of the calcification, heavy plaque burden and high prevalence of total occlusion. Furthermore, dynamic forces (compression, torsion, bending, lengthening and shortening) found within the femoropopliteal ar-tery impose stress on any endoprosthesis, potentially causing fracture and accelerated restenosis. Wire-In-terwoven Nitinol Stent demonstrates excellent initial outcomes and durable patency in the femoropopliteal arteries, with no fractures seen at follow-up.
Case report: A 60 years old men, obese, former smo-ker, presents with intermittent claudication since one month. The patient history prior to current observa-tion includes high blood pressure having a high car-diovascular risk, multivessel coronary artery disease (with stent eluting stent angioplasty in circumflex ar-tery 8 months ago prior to current presentation) and peripheral artery disease class IIB Leriche-Fontaine. Six months ago the patient underwent lower limb ar-teriography that revealed proximal total occlusion on left popliteal artery (Fig 1) with ankle brachial index (ABI) of 0.3. Subsequently the patient was submitted to percutaneous transluminal balloon angioplasty (4.0x80mm balloon inflated at 6 to 14 atmospheres) (Fig 2) by ultrasound guided retrograde approach trou-gh left posterior tibial artery with good angiographic result (Fig 3) and clinical symptoms remission (ABI increased at 1.0). Prior to retrograde approach the anterior approach trough the common femoral artery was tented twice, but it was unsuccessful – obese patient, calcified lesion. The patient was discharged with optimal drug treatment recommendations (statins, antiplatelet therapy and vasodilator).
In context of symptomatology recurrence at current presentation in left lower limb with ABI 0.4, the patient underwent a second lower limb arteriography that revealed reocclusion on the left popliteal artery (Fig 4). The treatment choice in this setting was percutaneous transluminal angioplasty with a self-expanding wire-interwoven nitinol stent (Supera) by ultrasound guided retrograde approach trough left posterior tibial artery with good angiographic result (Fig. 5, Fig. 6, Fig. 7, Fig. 8). The ABI measured invasively after angioplasty in-creased at 1.1.
Case particularity: In this case for therapeutic purpose it was used the ultrasound guided retrograde approach trough posterior tibial artery. Being an obese patient with an intense calcified lesion on the left popliteal artery and with a history of two failed anterograde approaches through left femoral artery, the retrograde approach remained the only option in these patient.
The surgical treatment of this patient was discussed; dual antiplatelet therapy initiated since drug eluting stent angioplasty on circumflex artery was made (less than one year prior to current presentation) represents a relative contraindication for surgical treatment.
Thus, in context of reocclusion of left popliteal artery at 6 months after balloon angioplasty in a patient with a relative contraindication for surgical treatment, our in-terventional cardiologist decided to perform percuta-neous transluminal angioplasty with a self-expandable wire-interwoven nitinol stent (Supera 5.0×150 mm); this stents type are indicated for arterial lesions located in areas of particularly high flexion because it provides a high degree of flexibility and a superior radial strength compared with its tubular stent competitors.
Conclusion: For high flexion region such as popliteal artery, balloon angioplasty was a relatively short-term solution (six months symptoms free) despite optimal medical treatment. Therefore interventional treatment with self-expandable wire-interwoven nitinol stents (stents able to tolerate the mechanical forces – extension, compression, flexion and torsion – that have previously caused stent fractures) it was a feasible treatment choice for this patient.
List of abreviations: ABI – ankle brachial inde

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)