Percutaneous Femoral Artery Angioplasty with Stent-in-Stent Technique and Tirofiban Administration

Obstruction of the femoral artery from intrastent thrombosis.
Left femoral artery showing no obstruction after the first percutaneous transluminal angioplasty procedure.
Left femoral artery angiography 3 minutes after first percutaneous transluminal angioplasty showing partial obstruction.
(A, B) Left femoral artery angiography 7 minutes after first percutaneous transluminal angioplasty procedure showing complete reobstruction.
Left femoral angiography showing artery opened with intrastent prolapse of the plaque.
Left femoral angiography after second percutaneous transluminal angioplasty procedure with stent-in-stent placement and tirofiban administration.
Left femoral angiography 30 minutes after second percutaneous transluminal angioplasty: final result.

Vittorio Ambrosini, MD, Salvatore Battaglia, MD, Angelo Cioppa, MD,
Letizia Lo Muzio, MD, Luigi Salemme, MD, Giovanni Sorropago, MD, Tullio Tesoria, MD, Paolo Rubino, MD

Percutaneous transluminal angioplasty (PTA) of the femoral artery is one method that has been used for many years, especially for patients with a high level of surgical risk. The use of stents alongside the traditional balloon techniques has further improved the results. In spite of this, patients with multiple risk factors (such as smoking, hypertension, diabetes, dyslipidemia, etc.) still demonstrate very high rates of restenosis. The traditional pharmacological structure (pentoxiphylline, aspirin, heparin, ticlopidine, etc.) cannot guarantee reliable prevention against restenosis. We describe a case of percutaneous angioplasty for an obstruction of the lower left femoral artery. The artery had subsequent in-stent restenosis. We demonstrate that a stent/angioplasty technique along with the use of tirofiban, a new platelet glycoprotein IIb/IIIa receptors antagonist, can be an effective treatment in both the short- and long-term for the treatment of a peripheral artery with acute thrombosis.

Case Report. A 62-year-old female patient who was married with 4 children presented at our institution. She was dyslipidemic and hypertensive. History was notable for hereditary arterial disorder, insulin-dependent diabetes mellitus for more than 20 years, and ischemic heart disease. She previously suffered an anterior heart attack, at which time she was found to have severe coronary disease of the left anterior descending coronary artery (which was treated with double coronary angioplasty with stent implantation) widespread arterial disease in the femoral iliac axis with intermediate multiple stenoses to the left and right as well as a subocclusive stenosis of the distal left femoral artery (which was treated with angioplasty and implantation of a 3.0 x 18 mm S670 AVE stent for acute ischemia of the limb).
The patient apparently enjoyed good health for about 5 months, after which she arrived in our department complaining about her leg; she had further typical symptoms of violent cruralgia, parestesy, cold and marbled skin, and absence of tibial and dorsalis pedis arterial pulses.
An echo-Doppler found an obstruction in the left femoral artery in the intrastent section with absence of flow after the obstruction. A digital vascular angiography followed after positioning a 6 French (Fr) pigtail catheter into the right femoral artery. The angiography results confirmed the obstruction in the left lower femoral artery to be intrastent thrombosis (Figure 1).
The patient was given ticlopidine and aspirin. We decided to attempt to clear the obstruction. We inserted a 6 Fr sheath into the left humeral artery and positioned the 6 Fr multipurpose guide catheter loaded onto a 0.35´´ x 260 cm guide. The 0.014´´ BMW guidewire (Guidant Corporation, Temecula, California) was introduced into the middle section of the artery but stopped in the intrastent thrombosis, unable to pass through the obstruction; only later, with the help of a balloon dilator (3.0 x 20 mm seayet) did we manage to pass through the obstruction with the guidewire. We continued multiple dilations with restoration of flow and with good visualization of the after flow, showing a successive stenosis of 30% just after the stent (Figure 2). The patient reported a notable weakening of the previously described symptoms. After 3 minutes, the check angiography confirmed a long and critical restenosis that included the sections proximal and distal to the stent (Figure 3). Angiography at 7 minutes confirmed renewed obstruction of the artery because of an acute thrombosis in the intrastent section (Figures 4A and 4B) and an obvious reappearance of the painful symptoms.
We proceeded to remove the obstruction by dilating the intrastent section as well as the sections distal and proximal to the stent with a 3.0 x 20 mm balloon. Angiography showed partial clearance of the artery with evidence of residual thrombosis from a probable prolapse of intrastent plaque as well as new platelet activity (Figure 5); we continued with the stent-in-stent implant using a 3.0 x 18 mm NIR Royal Advance stent to completely cover the previous stent implant (Figure 6). Inflation was performed for 30 seconds at 16 atmospheres. Extra dilations of the sections proximal and distal to the stent were activated with simultaneous administration of a bolus dose of 10 µg/kg tirofiban (Aggrastat). Tirofiban was then continued as an infusion of 0.15 µg/kg/minute for 36 hours. The angiography result, even after 30 minutes from start to finish, showed good downstream flow (Figure 7).
The patient was discharged on the third day with continuing clearance of the vessel in the intrastent section and a good flow proximal and distal to the stented section, which was proved both clinically and by a Doppler check-up. The clinical and instrumental 6-month follow-up examinations confirmed the absolute clearance of the arterial section as well as the functional artery in the limb.

Discussion. Peripheral vascular disease is frequently localized by the bisection of the aorta at the detachment of the vessel in the popliteal crease. Both balloon angioplasty and the endovascular stenting system can be used alone or in conjunction with conventional surgery.1 The debate continues about which therapy is more appropriate for acute ischemia of lower limbs where obstructive or sub-obstructive thrombotic stenosis is present.
Some authors have proven that percutaneous transluminal angioplasty of the lower femoral and popliteal arteries is worsened by a high percentage of clinical failure (progression of the ateromasica post-angioplasty pathology in 67% of treated patients) and so believe that this method is only useful for the treatment of disease in focal lesions of the femoral and popliteal arteries.2
The Seedawy group in Great Britain maintain that angioplasty of the lower femoral artery in the claudication intermittens is not effective in the majority of patients.3 Other authors have proven the usefulness and effectiveness of PTA, with even better long-term results than surgical treatment,4,5 so they consider it to be a reliable and safe alternative to surgical treatment itself.6
The advantages of PTA associated with stenting include the low morbidity and mortality rate, shorter hospitalization time, preservation of the saphenous vein for future cardiac or limb surgical bypass operation, and reduced costs.7 Many patients with peripheral vascular disease also have an associated cerebrovascular and coronary disorder, and thus an increased risk factor for general anesthetics and major surgery.8
The usual symptoms requiring PTA are claudication that limits lifestyle, pain when resting, ischemic ulcers and slow healing wounds causing vascular risk. The most reliable test, with high levels of sensitivity and specificity for peripheral arterial pathology, is the ankle-brachial index (ABI); i.e., the ratio of ankle systolic blood pressure to arm systolic blood pressure. A reading of 0.75 is considered normal; a reading between 0.40–0.75 suggests an arterial obstruction with claudication; and a value < 0.40 suggests a significant arterial obstruction with critical ischemia of the limb.9 Numerous studies demonstrate that an ABI gain greater than 0.1 determines a significant symptomatic improvement of the femoral and popliteal sections one year after PTA.10–12
In many studies, the difference in clinical improvement between patients subjected to PTA only versus PTA with stenting was undeniable.13,14 The main problems of PTA with stenting, which is particularly useful in cases of dissection, are intimal hyperplasia15 and the progression of atherosclerosis.16 For these reasons, medications are simultaneously administered while angioplasty with stenting is performed; some of these medications, like terbinafine,17 have been shown to be ineffective in preventing and/or limiting post-angioplasty in-stent restenosis.
Some studies have proven the ability of platelet glycoprotein IIb/IIIa receptor antagonist to reduce peri- and post-procedural thrombotic complications in endovascular procedures,22 even though complications are increased by a high percentage of hemorrhage.
Our experience, even though limited to a single case at the moment, brings us to the conclusion that peripheral angioplasty with stent implantation, when associated with simultaneous intra- and post-procedural administration of a platelet glycoprotein IIb/IIIa receptors antagonist (in this case, tirofiban) is a technically feasible procedure that is safe and effective, with reasonable results at both medium- and long-term follow-up, thus representing a reasonable, therapeutical option for the treatment of acute peripheral arterial ischemia syndrome.

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