Healing of femoral artery dissection after drug-coated balloon angioplasty: A case report with intravascular ultrasonography and angioscopy images

Abstract

Early 80s male with intermitted claudication underwent endovascular therapy for atherosclerotic stenosis at left external iliac artery and middle of superficial femoral artery. Patient also had chronic atrial fibrillation, diabetes mellitus, and hypertension. After stent deployment for external iliac artery lesion, a short superficial femoral artery lesion was performed with angioplasty using drug-coated balloon. The drug-coated balloon angioplasty resulted in 50% residual stenosis with linear dissection; however, provisional stenting was not performed as decent ante-grade blood flow allowed 10 extra minutes. Medication involved ongoing use of aspirin 100 mg and rivaroxaban 15 mg. Angiography post 3 months from index procedure showed external iliac artery and superficial femoral artery patency and healing of intimal dissection at superficial femoral artery lesion was estimated by intravascular ultrasonography. In angioscopy findings, red thrombus was seen in dissection cavity.

Introduction

Effective endovascular therapy for femoropopliteal segment is spreading around the world, though high-risk cases and lesions for vessel patency after procedure remain. ¹ To solve this problem, new approaches are being developed using advanced drug technologies, including a promising ‘nothing left behind’ strategy.^2,3 Drug-coated balloon (DCB) angioplasty is a hopeful treatment; however, long-term drug effects are uncertain because DCB has not been extensively used in peripheral intervention yet. We are presently following a case where healing of dissection is apparent 3 months after DCB angioplasty was performed in the femoropopliteal segment.

Case report

An early 80s male presented for left leg intermittent claudication caused by atherosclerotic stenosis at left external iliac artery (EIA) and middle of superficial femoral artery (SFA). He also had chronic atrial fibrillation, diabetes mellitus, and hypertension. His informed consent allowed us to perform endovascular therapy. According to intravascular ultrasonography (IVUS) images, 8.0–40 mm S.M.A.R.T. control stent (Cordis, USA) was deployed for EIA lesion by contra-lateral approach and short (2 cm lesion length) SFA lesion was decided with DCB angioplasty. After preparation using 4.0–40 mm NSE balloon (Nipro, Japan), angioplasty using DCB (5.0–40 mm IN.PACT Admiral; Medtronic, USA) was done at nominal pressure for 5 min and resulted in 50% residual stenosis with linear dissection. Provisional stenting was not done because decent ante-grade blood flow allowed 10 extra minutes. Medication involved ongoing use of aspirin 100 mg and rivaroxaban 15 mg. Angiography 3 months from index procedure showed EIA and SFA patency and healing of intimal dissection at SFA lesion was estimated by IVUS (Figure 1). In angioscopy findings, red thrombus was seen in dissection cavity (Figure 2) but no white granular materials were seen at DCB dilated segment.

Figure 1.

Panels A and B show digital subtraction angiography of superficial femoral lesion at the end of index procedure and at 3 months’ follow-up period. Black arrows indicate the segments where intravascular ultrasonography (IVUS) findings were obtained. Panels C and D show those IVUS findings and white arrows indicate intimal flap.

Figure 2.

Angioscopy reveals red thrombus at dissection cavity (indicated by white arrows).

Discussion

We reported that balloon angioplasty in SFA segment resulted in optimal dilatation and good outcomes were achieved; ⁴ however, balloon angioplasty sometimes leads to major intimal dissection. Depending on the magnitude of dissection occurrence, restenosis risk would be higher. ⁵ Based on these experiences, provisional stenting had been selected for dissection occurrences after balloon angioplasty in past nitinol stenting era. However, healing effect of DCB for dissection has been reported in coronary intervention recently.^6,7 In our case, linear dissection occurred after DCB angioplasty at the end of index procedure and healing change of intimal flap was in IVUS findings 3 months later. We feel this observation could be important, showing possibility of dissection healing effect of DCB even in peripheral intervention – possibly similar to coronary intervention.

It is well-known that shorter lesions could have better prognosis in endovascular therapy. ⁸ The clinical course of our case might simply depend on its short lesion length, but further case studies might be necessary.

From angioscopy findings, thrombus might be suspect to have some role in the healing process of dissection from our case, but to the best of our knowledge, no reports have discussed these findings.

Using direct oral anticoagulants (DOACs) after procedure therapy, a recent report ⁹ showed non-inferior effect on vessel patency compared with standard dual antiplatelet therapy after SFA intervention. That report might involve almost half of patients who ended up with non-stenting strategy; however, prevalence of DCB use was not described.

Further prospective randomized investigation about dissection healing effect of DCB, role of thrombus, and efficacy of combination with DOAC use in peripheral intervention should be studied.

Conclusion

In this case, possible healing effect of DCB for dissection occurred in SFA segment was estimated in angiography and IVUS findings.