Endovascular intervention using combined percutaneous access in a patient with recurrence of critical ischemia after repeated bypass operations on arteries of the lower extremities (clinical case)

Unsatisfactory long-term results of shunting operations on the arteries of the lower extremities are most often caused by a stenotic process followed by thrombosis in the anastomotic zone, especially in combination with the progression of the underlying disease and the spread of obstructive atherosclerotic lesions on the inflow and outflow arteries. A clinical case of endovascular treatment of a patient with peripheral arterial disease is presented, who previously underwent 3 reconstructive bypass operations on the arteries of the lower extremities within 15 months before hospitalization, but again sought medical help due to the recurrence of critical ischemia of the left lower extremity. Considering the high risk of repeated open surgery due to the patient’s comorbidity (diabetes mellitus and extensive Q-myocardial infarction, suffered after the first bypass surgery), as well as gross scar changes after previous vascular operations, it was decided to perform endovascular intervention using a non-standard combined percutaneous approach. Iliac artery stenosis and post-thrombotic occlusion of the popliteal artery in the area of the distal anastomosis of the femoral-popliteal bypass graft on the left side were detected on the preoperative MSCT with intravenous contrast enhancement. Because of the gross postoperative scars, we could not use standard percutaneous approaches through any of the femoral arteries. Access through the arteries of the upper limbs also did not ensure the operation on all affected segments due to the long distance to the intervention zone and absence of instruments of the required length. Therefore, in order to maximally solve the tasks of the operation, we simultaneously used an antegrade left transaxillary access and a transpedal retrograde access through the left foot artery. Thus, the patient underwent simultaneous balloon angioplasty of stenoses of the common and external iliac arteries on the left side by transaxillary access, as well as balloon angioplasty and implantation of a coronary drug-eluting stent in the popliteal artery in the area of the distal anastomosis of the femoral-popliteal bypass graft by retrograde transpedal access on the left. As a result, the magistral arterial blood flow of the limb and the function of the shunt were completely restored with a good angiographic and clinical result.The applied methods of endovascular treatment have shown high efficiency and can be recommended as an alternative to traditional