Percutaneous Endoluminal Bypass for Lower Extremity Perfusion in High-Risk Nonsurgical Candidates

Kailin Opella, Andrew Ibrahim, Vivie Tran, Annmarie Farag, Minnie Tran, Mohammad Ansari

PAD Center of Excellence, Texas Tech University Health Sciences Center, Lubbock, Texas

Introduction

Peripheral arterial disease (PAD) is a growing concern in the United States. PAD occurs when fatty deposits or calcium build up in the arteries causing a narrowing and reduction of blood flow. Historically, PAD was treated through surgical bypass interventions, but recent advancements in medicine introduced percutaneous endovascular bypass, for non-surgical candidates. 

Lower extremity percutaneous endovascular bypass is a minimally invasive procedure that creates a new pathway for blood flow around a blocked or narrowed section of an artery. We present a high-risk nonsurgical patient in which the use of percutaneous endovascular bypass was the final recourse in achieving perfusion in the left lower extremity. 

Case Presentation

Male, age 82, with a PMH of PAD, CAD, HTN, DM2, and smoking presented with claudication, lower extremity rest pain at times, and exertional dyspnea. Previous interventions included unsuccessful medical management. Diagnostics tests included transthoracic echocardiogram which showed a decreased left ventricular ejection fraction and abnormal stress tests. Peripheral angiography depicted stenosis throughout multiple vessels and chronic total occlusion (CTO) of the superficial femoral artery (SFA) and popliteal artery (PA). 

Right femoral artery access was used to perform percutaneous transluminal angioplasty (PTA) of the SFA and PA. After several unsuccessful attempts of balloon angioplasty, orbital atherectomy (OA) was performed to allow stenting. The Eluvia stent was placed in the proximal SFA and the Everflex stent was placed in the distal SFA. Finally, a Gore Viabahn stent was deployed to the medial SFA, overlapping the pSFA and dSFA stents. Percutaneous endoluminal bypass was used to restore perfusion through the lower extremity and treat EIA, CFA, SFA, and PA occlusion. 

Discussion

This case illustrates the benefits of employing percutaneous endoluminal bypass in high-risk nonsurgical candidates with severe, complex vessel occlusion. The use of multiple stents, including the Gore Viabahn stent created a lumen in a CTO vessel and is important for advancing future treatments of PAD. With endovascular treatments and technology improving, percutaneous endovascular bypass should be considered for patients who are not surgical candidates to treat PAD.