The fluoro-less and contrast-less peripheral endovascular intervention: Halfway there.
BACKGROUND
Percutaneous endovascular revascularization requires the use of fluoroscopic guidance and radiopaque contrast. We present a successful intervention without the use of iodinated contrast.


METHODS
A 92-year-old man with dry gangrene involving the second and fourth left toes had acute on chronic kidney injury. Arterial duplex showed severe stenosis in bilateral superficial femoral arteries (SFAs). Fluoroscopic and ultrasound guidance and intravascular imaging were used to avoid iodinated contrast. After right to left femoral crossover, the entire left SFA was imaged with ultrasound. The lesion was delineated with radiopaque measuring tapes then wired. Near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS) imaging were performed. Points of interest were correlated with corresponding radiopaque markings on the ruler. Stenting and post-dilation resulted in complete stent expansion and no evidence of dissection by IVUS. The total procedure time was 113min and the total radiation dose 813mGy. The day after the procedure, there was a palpable dorsalis pedis pulse. He was discharged to inpatient rehabilitation on dual antiplatelet therapy.


CONCLUSIONS
Contrast and radiation continue to limit the feasibility of endovascular angiography and intervention. Carbon dioxide (CO2) digital subtraction angiography is an alternative for these patients but has several disadvantages. Previously proposed projects demonstrated the real potential of performing endovascular peripheral intervention without fluoroscopy or contrast.


CONCLUSIONS
This case is a clear demonstration of a successful use of a combination of fluoroscopy, ultrasonography and intravascular imaging to achieve a successful endovascular intervention to treat critical limb ischemia, without the use of iodinated contrast.
Department of Cardiovascular Disease, Oakland University-William Beaumont School of Medicine at Beaumont Health System, Royal Oak, MI. Electronic address: g.ephrem@gmail.com.
Georges
G
Ephrem
Department of Cardiovascular Disease, Oakland University-William Beaumont School of Medicine at Beaumont Health System, Royal Oak, MI.
Sireesha
S
Garikipati
Department of Cardiovascular Disease, Oakland University-William Beaumont School of Medicine at Beaumont Health System, Royal Oak, MI.
Ivan D
ID
Hanson
D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000295:instrumentation / Q000379:methods*; D002245:Carbon Dioxide / Q000008:administration & dosage; D002932:Cineangiography; D003251:Constriction, Pathologic; D003287:Contrast Media / Q000008:administration & dosage / Q000009:adverse effects*; D016638:Critical Illness; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000503:physiopathology; D005471:Fluoroscopy; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D064847:Multimodal Imaging; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D011237:Predictive Value of Tests; D011829:Radiation Dosage; D000069079:Radiation Exposure / Q000009:adverse effects; D012720:Severity of Illness Index; D019265:Spectroscopy, Near-Infrared; D015607:Stents; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional
D003287:Contrast Media; D002245:Carbon Dioxide
Contrast; Fluoroscopy; Intervention; Peripheral