Successful endovascular treatment using biopsy forceps for iliac artery stenosis with an organized thrombus

Transcription

1 Successful endovascular treatment using biopsy forceps for iliac artery stenosis with an organized thrombus Taisuke Sato 1, Yasuhiro Takahashi 1, Kenta Onodera 1 Reiko Shiomura 1, Hiroki Goda 1, Isamu Fukuizumi 1, Wataru Shimizu 2 1. Department of Cardiology, 2. Department of Cardiovascular Medicine, Nippon Medical School

2 Disclosure Speaker name: Taisuke Sato I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest

3 Case A 77-year-old woman who had hypertension, dyslipidemia, and chronic lymphatic leukemia complained of recurrence of intermittent claudication. She underwent multiple endovascular treatments (EVTs) of the right external iliac artery. During the aforementioned duration, 50-mg clopidogrel was used continuously and 100-mg aspirin was additionally used only 1 month after stent deployment.

4 Case A 77-year-old woman who had hypertension, dyslipidemia, and chronic lymphatic leukemia complained of recurrence of intermittent claudication. She underwent multiple endovascular treatments (EVTs) of the right external iliac artery. During the aforementioned duration, 50-mg clopidogrel was used continuously and 100-mg aspirin was additionally used only 1 month after stent deployment.

5 Case A 77-year-old woman who had hypertension, dyslipidemia, and chronic lymphatic leukemia complained of recurrence of intermittent claudication. She underwent multiple endovascular treatments (EVTs) of the right external iliac artery. During the aforementioned duration, 50-mg clopidogrel was used continuously and 100-mg aspirin was additionally used only 1 month after stent deployment.

6 1 st EVT Right EIA After stenting Right proximal EIA occlusion SMART stent 10.0/60 mm

7 2 nd EVT After stenting PG 35mmHg SMART stent 7.0/40 mm

8 3 rd EVT NSE PTA 5.0/40 mm

9 4 th EVT SAVERX 5.0/20 mm PG 57mmHg

10 Case However, she presented with severe intermittent claudication of the right lower limb again 4 months after the last EVT. Her right ankle-brachial index(abi) was decreased to Therefore, we performed lower extremity angiography.

11 Case However, she presented with severe intermittent claudication of the right lower limb again 4 months after the last EVT. Her right ankle-brachial index(abi) was decreased to Therefore, we performed lower extremity angiography.

12 Case However, she presented with severe intermittent claudication of the right lower limb again 4 months after the last EVT. Her right ankle-brachial index(abi) was decreased to Therefore, we performed lower extremity angiography.

13 Angiography

14 IVUS

15 Case We suspected that the structure was a thrombus, intimal dissection, or another abnormality. Stent deployment or balloon angioplasty for the lesion could disturb the investigation of the cause of the restenosis. Furthermore, we thought that aspiration of the structure would be difficult on the basis of assessment of IVUS findings. Therefore, a biopsy forceps device was used for removal of the structure.

16 Case We suspected that the structure was a thrombus, intimal dissection, or another abnormality. Stent deployment or balloon angioplasty for the lesion could disturb the investigation of the cause of the restenosis. Furthermore, we thought that aspiration of the structure would be difficult on the basis of assessment of IVUS findings. Therefore, a biopsy forceps device was used for removal of the structure.

17 Case We suspected that the structure was a thrombus, intimal dissection, or another abnormality. Stent deployment or balloon angioplasty for the lesion could disturb the investigation of the cause of the restenosis. Furthermore, we thought that aspiration of the structure would be difficult on the basis of assessment of IVUS findings. Therefore, a biopsy forceps device was used for removal of the structure.

18 Case We suspected that the structure was a thrombus, intimal dissection, or another abnormality. Stent deployment or balloon angioplasty for the lesion could disturb the investigation of the cause of the restenosis. Furthermore, we thought that aspiration of the structure would be difficult on the basis of assessment of IVUS findings. Therefore, a biopsy forceps device was used for removal of the structure.

19 Strategy Stent IVUS Structure Biopsy forceps Optimo occlusion catheter

20 Procedure Fluoroscopy IVUS The structure was excised using a biopsy forceps under fluoroscopic and IVUS image guidance.

21 Final angiography

22 IVUS

23 Removed structure Histological diagnosis: Organized thrombus

24 Clinical course after EVT After endovascular treatment, her intermittent claudication had disappeared. Her right ABI was improved from 0.55 to The CYP2C19 genetic polymorphism, which was checked after the last EVT was CYP2C19 (*1/*2) and showed that she was an intermediate metabolizer. Therefore, the clopidogrel dose was increased to 75 mg and dual antiplatelet therapy was performed 1 month after EVT.

25 Clinical course after EVT After endovascular treatment, her intermittent claudication had disappeared. Her right ABI was improved from 0.55 to The CYP2C19 genetic polymorphism, which was checked after the last EVT was CYP2C19 (*1/*2) and showed that she was an intermediate metabolizer. Therefore, the clopidogrel dose was increased to 75 mg and dual antiplatelet therapy was performed 1 month after EVT.

26 Clinical course after EVT After endovascular treatment, her intermittent claudication had disappeared. Her right ABI was improved from 0.55 to The CYP2C19 genetic polymorphism, which was checked after the last EVT was CYP2C19 (*1/*2) and showed that she was an intermediate metabolizer. Therefore, the clopidogrel dose was increased to 75 mg and dual antiplatelet therapy was performed 1 month after EVT.

27 Clinical course after EVT After endovascular treatment, her intermittent claudication had disappeared. Her right ABI was improved from 0.55 to The CYP2C19 genetic polymorphism, which was checked after the last EVT was CYP2C19 (*1/*2) and showed that she was an intermediate metabolizer. Therefore, the clopidogrel dose was increased to 75 mg and dual antiplatelet therapy was performed 1 month after EVT.

28 Discussion In this case, restenosis in the right EIA was repeated many times. Some treatment options such as balloon angioplasty, stent deployment, or aspiration were considered at the fifth recurrence of intermittent claudication. However, the first two methods could disturb the investigation of the cause of the restenosis, and the last method could be ineffective. Removal of the structure by using a biopsy forceps device with concurrent viewing under fluoroscopy and IVUS imaging, which was safely and effectively performed, led to optimal dilation of the lesion without conventional angioplasty and diagnosis of the cause of the restenosis.

29 Discussion In this case, restenosis in the right EIA was repeated many times. Some treatment options such as balloon angioplasty, stent deployment, or aspiration were considered at the fifth recurrence of intermittent claudication. However, the first two methods could disturb the investigation of the cause of the restenosis, and the last method could be ineffective. Removal of the structure by using a biopsy forceps device with concurrent viewing under fluoroscopy and IVUS imaging, which was safely and effectively performed, led to optimal dilation of the lesion without conventional angioplasty and diagnosis of the cause of the restenosis.

30 Discussion In this case, restenosis in the right EIA was repeated many times. Some treatment options such as balloon angioplasty, stent deployment, or aspiration were considered at the fifth recurrence of intermittent claudication. However, the first two methods could disturb the investigation of the cause of the restenosis, and the last method could be ineffective. Removal of the structure by using a biopsy forceps device with concurrent viewing under fluoroscopy and IVUS imaging, which was safely and effectively performed, led to optimal dilation of the lesion without conventional angioplasty and diagnosis of the cause of the restenosis.

31 Discussion This patient was an intermediate metabolizer of CYP2C19. Moreover, 50-mg clopidogrel, whicih was less than the standard dose, was prescribed by her primary care physician for her had blood disorder. The aforementioned factors could possibly induce stent thrombosis.

32 Discussion This patient was an intermediate metabolizer of CYP2C19. Moreover, 50-mg clopidogrel, whicih was less than the standard dose, was prescribed by her primary care physician for her had blood disorder. The aforementioned factors could possibly induce stent thrombosis.

33 Discussion This patient was an intermediate metabolizer of CYP2C19. Moreover, 50-mg clopidogrel, whicih was less than the standard dose, was prescribed by her primary care physician for her had blood disorder. The aforementioned factors could possibly induce stent thrombosis.

34 Conclusion Endovascular treatment using biopsy forceps was safe and effective for the restenotic lesion with an organized thrombus. The cause of the stent thrombosis in the present case might be associated with the intermediate metabolizer of CYP2C19 and the administration of low-dose clopidogrel.

35 Sumida River Fire Works Festival Tokyo Skytree (634 m) Sumo Stadium Hokusai s birth place and the Sumida Hokusai Museum

36 Successful endovascular treatment using biopsy forceps for iliac artery stenosis with an organized thrombus Taisuke Sato 1, Yasuhiro Takahashi 1, Kenta Onodera 1 Reiko Shiomura 1, Hiroki Goda 1, Isamu Fukuizumi 1, Wataru Shimizu 2 1. Department of Cardiology, 2. Department of Cardiovascular Medicine, Nippon Medical School