Journal of Invasive Cardiology

ABSTRACT: We describe the case of a 70-year old male with total occlusion of the left superficial femoral artery (SFA) treated with percutaneous implantation of a self-expanding nitinol stent. The patient’s course post-stent implantation was complicated by the development of stent fracture with SFA perforation and a large, compressive  intramuscular hematoma with deep venous thrombosis (DVT). The patient returned to the catheterization laboratory where the fracture and perforation were successfully treated by the deployment of another stent across the fracture site. The DVT was initially treated with an inferior vena cava filter until anticoagulation could safely be instituted.

J INVASIVE CARDIOL 2008;20:479–481

Stent fracture is a rare complication following revascularization and stenting of the superficial femoral artery (SFA). Stent fracture is most often asymptomatic, but has been associated with an increased risk of restenosis. We report a case of stent fracture following treatment of an SFA occlusion complicated by SFA perforation and intramuscular hematoma that led to deep venous thrombosis.

Case Report. A 70-year-old male with hypertension, hyperlipidemia, peripheral arterial disease (PAD) and coronary artery disease was referred to our institution for the evaluation of severe claudication and intermittent rest pain of the left leg.

Magnetic resonance angiography of the lower extremities demonstrated a total occlusion of the left SFA and a severe mid-popliteal artery stenosis. The patient refused bypass surgery.

The patient underwent angiography of the left-lower extremity using a contralateral approach. Angiography confirmed a total occlusion of the mid-to-distal left SFA approximately 15 cm in length (Figure 1). The distal SFA reconstituted via collaterals from the deep femoral artery. The findings also confirmed the severe popliteal artery lesion.

After discussion with the patient, a decision was made to attempt percutaneous revascularization of the left SFA. After the use of multiple wires and support catheters, the total occlusion was crossed with a Miracle Bros 6 0.014 inch wire (Abbott Vascular, Abbott Park, Illinois) advanced subintimally to the distal reconstitution site. An Outback Re-Entry Catheter (Cordis Corp., Miami Lakes, Florida) was used to re-enter the true lumen of the distal SFA.

The lesion was dilated with a 3.5 mm x 120 mm Amphirion balloon (ev3, Inc., Plymouth, Minnesota) and stented with 2 overlapping 6.0 mm FlexStar self-expanding stents (Edwards Lifesciences, Irvine, California). There were areas within the stents that appeared underexpanded and these were treated with a 5.0 mm Submarine Plus balloon (ev3) inflated to a maximal pressure of 10 atm. The mid-popliteal artery lesion was treated with a SilverHawk LS atherectomy device (FoxHollow Technologies, Inc., Redwood City, California) with a good angiographic result.

The final angiogram demonstrated good stent apposition with brisk antegrade flow and no evidence of stent fracture (Figure 2). The patient was observed overnight and discharged home the following morning on dual antiplatelet therapy of aspirin 325 mg and clopidogrel 75 mg daily.