Balloon Embolectomy of a Cylindrical Dissected Plaque That Complicated Performing Superficial Femoral Artery Angioplasty

Home , Angioplasty, Embolectomy

Ju-Seok Kim, MD1, In-Joung Lee, MD1, Su Jin Kim, MD1, Sang-Ho Jo, MD1, Hyun-Sook Kim, MD1, Goo-Yeong Cho, MD1, Young Jin Choi, MD1, Chong-Yun Rhim MD1, Kun Il Kim, MD2 and Hye-Rim Park, MD3 1Division of Cardiology, Department of Internal Medicine, 2Thoracic and Cardiovascular Surgery and 3Pathology, Hallym University Sacred Heart Hospital, Anyang, Korea

ABSTRACT

We report here on a case of successfully removing a calcified plaque embolus that complicated performing angioplasty. A 67 year-old woman underwent percutaneous transluminal angioplasty for a stenosis of the right superficial femoral artery (SFA). The angiogram showed a marked stenosis at the mid-portion of SFA and diffuse circular calcification along the atheroma rim was seen on the computed tomographic angiography. Although balloon inflation was attempted on the lesion, it was not fully dilated. After repeated balloon inflations, a radiopaque calcified atheroma was detached from the arterial wall and it migrated proximally along with withdrawing the balloon. The embolus was too extensive to be pulled out through the catheter sheath; therefore, a small balloon was inflated at the distal end of the embolic atheroma to anchor it and the embolus was removed with the balloon and the sheath system via an arteriotomized puncture site. A huge cylindrical atheroma that measured 4 cm in length was successfully removed. The final angiography showed a widened target site without any dye leakage. (Korean Circ J 2008;38:335-338)

KEY WORDS: Femoral artery; Angioplasty; Complication; Calcification.

Introduction tion in the right leg. The ankle-brachial index (ABI) of her right leg was 0.7. Angiography showed a markedly Endovascular therapy is the treatment of choice for stenosed TASC type A lesion in the mid-portion of Trans-Atlantic Inter-Society Consensus (TASC) type A the superficial femoral artery (Fig. 1A), and diffuse cir- infrainguinal lesions.1) The complications after perform- cular calcification along the atheroma rim was seen on ing percutaneous transluminal angioplasty (PTA) at computed tomographic angiography (CTA) (Fig. 1B and these lesions were reported to be less than 5%.2) We C). Despite inflating a 4.0×40.0 mm PowerflexTM bal- report here on a rare experience of a cylindrical embolus loon (Cordis, Johnson and Johnson Co., Miami, USA) that occurred during performing PTA in the superficial up to 20 atmospheres on the lesion, full dilation was femoral artery (SFA). The embolus was removed through not achieved, and on an inflation attempt with a larger an arteriotomy site, and the patient displayed a good balloon inflation, the radiopaque calcified atheroma was clinical outcome. detached from the arterial wall and it migrated proximally (Fig. 1D and E). The proximal movement of the Case embolus was augmented with withdrawing the balloon (Fig. 1F). The embolus was too extensive to be pulled A 67 year-old woman with diabetes and hyperten- through the catheter sheath; therefore, a 1.5×20.0 mm sion underwent PTA for Fontaine’s stage IIb1) claudica- SprinterTM balloon (Medtronic Co., MN, USA) was inflated at the distal end of the atheroma to anchor it

Received: January 3, 2008 and the embolus was drained with the balloon. A huge Revision Received: February 12, 2008 cylindrical atheroma that measured 4 cm in length was Accepted: February 16, 2008 successfully removed at the arterial puncture site, which Correspondence: Young Jin Choi, MD, Division of Cardiology, Depart- was opened wider via surgical incision. The mass was ment of Internal Medicine, Hallym University Sacred Heart Hospital, 896 bony hard with a whitish circle along the rim, and path- Pyeongchon-dong, Dongan-gu, Anyang 431-070, Korea Tel: 82-31-380-3877, Fax: 82-31-386-2269 ologic examination revealed a typical atherosclerotic E-mail: [email protected] plaque composed of lipid deposits and thickened fibrotic

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A B C

D E F

Fig. 1. The preprocedural femoral angiograms, the computed tomographic angiograms and embolization of the dissected plaque during angioplasty. The femoral angiogram showed a markedly narrowed lesion in the mid-portion of the right superficial femoral artery (A). Radiopaque density corresponding to calcium was seen within the arterial wall at the site of the stenosis on the computed tomographic angiography (B, white arrow). The non-enhanced computed tomography images revealed heavy calcification over an arc of approxi- mately 360 degree, which encircled the arterial lumen (C, white arrow). Fluoroscopy showed a radiopaque density corresponding to calcium within the arterial wall (D, black arrows). It was visible proximal to the initial site after balloon dilatation of the lesion (E). The radiopacity moved more proximally along with the withdrawal of the balloon, suggesting extensive local dissection and embolization of the plaque from the arterial wall (F). intimal tissue. In addition, it showed reduplication and is traumatic to arterial tissue, causing plaque fissuring fragmentation of the internal elastic lamina and thicken- and/or dissection.5) These types of traumatization of ar- ing of the media with fibrotic degeneration (Fig. 2C, D terial tissue are factors that contribute to acute procedural and E). The final angiography showed a widened target complications, which require either further catheter in- site without dye leakage, and the post-procedure ankle tervention or surgery.2) brachial index (ABI) improved to 0.9. The patient has In this case, dissection and embolization of the cal- remained symptom free for six months after the proce- cified atherosclerotic plaque occurred immediately after dure. dilating the balloon on the SFA lesion. According to the previous literature, most embolisms or dissections Discussion following balloon dilatation were successfully treated during the course of the angioplasty by performing PTA is an established procedure for most patients further procedures.2) In contrast to the prior reports, with focal stenotic lesions of the SFA due to its high the extent of dissection was tremendous in our patient technical success rate.1-4) Although the incidence of and the size of the bony hard embolus was also too PTA complications is quite low in these lesions,2) PTA huge to be taken out from the sheath percutaneously,

Ju-Seok Kim, et al.·337

B E

Fig. 2. The post-procedural femoral angiogram and the pathologic findings. A fragment of bony hard tubular tissue, measuring 4×0.5× 0.5 cm at its greatest dimension, was taken out from the femoral artery by surgical balloon embolectomy (A). After removal of the em- bolized atherosclerotic plaque, the angiogram demonstrated a fully opened artery without further intervention (B). Microscopic examination revealed reduplication and fragmentation of the internal elastic lamina and thickening of the media with fibrotic degeneration (C: H&E, ×12.5; D: H&E, ×100; E: verhoeff van Gieson, ×100). and so arteriotomy was required. Another therapeutic drical-shaped atheroma from the arterial wall. Artery option was deploying a stent to exclude the embolus dissection after balloon angioplasty frequently happens from the arterial lumen. However the embolus was un- adjacent to hard plaque, including calcification,6) and dilatable with prior balloon inflation and it was huge this previous report supports our hypothesis. in size; therefore, a stent could not pass the embolus. Although PTA is usually believed to be safe in TASC Although the pathologic examination failed to verify type A lesions, carefully evaluating the plaque charac- calcium deposited on the atheroma, the observed ra- teristics is required to predict complications that can diopacity of the atheroma on fluoroscopy and the CTA occur following intervention. In cases where diffuse, findings strongly support the calcification of the ath- heavy calcification is suspected, the possibility of mas- eroma. In this case, the calcium deposits on the atheroma sive dissection should be kept in mind and proper lay in circumferential manner, which created a bony management should be prepared. hard structure that was resistance to balloon dilation. As such, we think that the pressure of the inflated bal- REFERENCES loon might have been transferred to the adjacent arterial 1) Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Con- wall, and this resulted in separation of the entire cylin- sensus for the Management of Peripheral Arterial Disease (TASC

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