Page 1
Taisuke Sato1, Yasuhiro Takahashi1, Kenta Onodera1 Reiko
Shiomura1, Hiroki Goda1, Isamu Fukuizumi1, Wataru
Shimizu2
1. Department of Cardiology, The Fraternity Memorial Hospital
2. Department of Cardiovascular Medicine, Nippon Medical School
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Successful endovascular treatment using
biopsy forceps for iliac artery stenosis with
an organized thrombus
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Disclosure
Speaker name: Taisuke Sato
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest✔
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
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Case
• A 77-year-old woman who had hypertension,
dyslipidemia, and chronic lymphatic leukemia
complained of recurrence of intermittent claudication.
• She underwent multiple endovascular treatments (EVTs)
of the right external iliac artery.
• During the aforementioned duration, 50-mg clopidogrel
was used continuously and 100-mg aspirin was
additionally used only 1 month after stent deployment.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
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Case
• A 77-year-old woman who had hypertension,
dyslipidemia, and chronic lymphatic leukemia
complained of recurrence of intermittent claudication.
• She underwent multiple endovascular treatments (EVTs)
of the right external iliac artery.
• During the aforementioned duration, 50-mg clopidogrel
was used continuously and 100-mg aspirin was
additionally used only 1 month after stent deployment.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
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Case
• A 77-year-old woman who had hypertension,
dyslipidemia, and chronic lymphatic leukemia
complained of recurrence of intermittent claudication.
• She underwent multiple endovascular treatments (EVTs)
of the right external iliac artery.
• During the aforementioned duration, 50-mg clopidogrel
was used continuously and 100-mg aspirin was
additionally used only 1 month after stent deployment.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
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Right EIA After stenting
SMART stent 10.0/60 mmRight proximal EIA occlusion
1st EVT
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
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SMART stent 7.0/40 mm
After stenting
2nd EVT
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
PG 35mmHg
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NSE PTA 5.0/40 mm
3rd EVT
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
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SAVERX 5.0/20 mm
4th EVT
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
PG 57mmHg
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• However, she presented with severe intermittent
claudication of the right lower limb again 4 months
after the last EVT.
• Her right ankle-brachial index(ABI) was decreased to
0.55.
• Therefore, we performed lower extremity angiography.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Case
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• However, she presented with severe intermittent
claudication of the right lower limb again 4 months
after the last EVT.
• Her right ankle-brachial index(ABI) was decreased to
0.55.
• Therefore, we performed lower extremity angiography.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Case
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• However, she presented with severe intermittent
claudication of the right lower limb again 4 months
after the last EVT.
• Her right ankle-brachial index(ABI) was decreased to
0.55.
• Therefore, we performed lower extremity angiography.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Case
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Angiography
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
IVUS
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• We suspected that the structure was a thrombus, intimal
dissection, or another abnormality.
• Stent deployment or balloon angioplasty for the lesion
could disturb the investigation of the cause of the
restenosis.
• Furthermore, we thought that aspiration of the structure
would be difficult on the basis of assessment of IVUS
findings.
• Therefore, a biopsy forceps device was used for removal
of the structure.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Case
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• We suspected that the structure was a thrombus, intimal
dissection, or another abnormality.
• Stent deployment or balloon angioplasty for the lesion
could disturb the investigation of the cause of the
restenosis.
• Furthermore, we thought that aspiration of the structure
would be difficult on the basis of assessment of IVUS
findings.
• Therefore, a biopsy forceps device was used for removal
of the structure.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Case
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• We suspected that the structure was a thrombus, intimal
dissection, or another abnormality.
• Stent deployment or balloon angioplasty for the lesion
could disturb the investigation of the cause of the
restenosis.
• Furthermore, we thought that aspiration of the structure
would be difficult on the basis of assessment of IVUS
findings.
• Therefore, a biopsy forceps device was used for removal
of the structure.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Case
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• We suspected that the structure was a thrombus, intimal
dissection, or another abnormality.
• Stent deployment or balloon angioplasty for the lesion
could disturb the investigation of the cause of the
restenosis.
• Furthermore, we thought that aspiration of the structure
would be difficult on the basis of assessment of IVUS
findings.
• Therefore, a biopsy forceps device was used for removal
of the structure.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Case
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Strategy
Optimo occlusion catheter
Biopsy forceps
IVUSStructure
Stent
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The structure was excised using a biopsy forceps under fluoroscopic
and IVUS image guidance.
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
IVUSFluoroscopy
Procedure
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Final angiography
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
IVUS
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Removed structure
Histological diagnosis: Organized thrombus
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Clinical course after EVT
• After endovascular treatment, her intermittent
claudication had disappeared.
• Her right ABI was improved from 0.55 to 1.01.
• The CYP2C19 genetic polymorphism, which was
checked after the last EVT was CYP2C19 (*1/*2) and
showed that she was an intermediate metabolizer.
• Therefore, the clopidogrel dose was increased to 75 mg
and dual antiplatelet therapy was performed 1 month
after EVT.
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Clinical course after EVT
• After endovascular treatment, her intermittent
claudication had disappeared.
• Her right ABI was improved from 0.55 to 1.01.
• The CYP2C19 genetic polymorphism, which was
checked after the last EVT was CYP2C19 (*1/*2) and
showed that she was an intermediate metabolizer.
• Therefore, the clopidogrel dose was increased to 75 mg
and dual antiplatelet therapy was performed 1 month
after EVT.
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Clinical course after EVT
• After endovascular treatment, her intermittent
claudication had disappeared.
• Her right ABI was improved from 0.55 to 1.01.
• The CYP2C19 genetic polymorphism, which was
checked after the last EVT was CYP2C19 (*1/*2) and
showed that she was an intermediate metabolizer.
• Therefore, the clopidogrel dose was increased to 75 mg
and dual antiplatelet therapy was performed 1 month
after EVT.
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Clinical course after EVT
• After endovascular treatment, her intermittent
claudication had disappeared.
• Her right ABI was improved from 0.55 to 1.01.
• The CYP2C19 genetic polymorphism, which was
checked after the last EVT was CYP2C19 (*1/*2) and
showed that she was an intermediate metabolizer.
• Therefore, the clopidogrel dose was increased to 75 mg
and dual antiplatelet therapy was performed 1 month
after EVT.
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Discussion
• In this case, restenosis in the right EIA was repeated many
times.
• Some treatment options such as balloon angioplasty, stent
deployment, or aspiration were considered at the fifth
recurrence of intermittent claudication. However, the first
two methods could disturb the investigation of the cause
of the restenosis, and the last method could be ineffective.
• Removal of the structure by using a biopsy forceps device
with concurrent viewing under fluoroscopy and IVUS
imaging, which was safely and effectively performed, led
to optimal dilation of the lesion without conventional
angioplasty and diagnosis of the cause of the restenosis.
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Discussion
• In this case, restenosis in the right EIA was repeated many
times.
• Some treatment options such as balloon angioplasty, stent
deployment, or aspiration were considered at the fifth
recurrence of intermittent claudication. However, the first
two methods could disturb the investigation of the cause
of the restenosis, and the last method could be ineffective.
• Removal of the structure by using a biopsy forceps device
with concurrent viewing under fluoroscopy and IVUS
imaging, which was safely and effectively performed, led
to optimal dilation of the lesion without conventional
angioplasty and diagnosis of the cause of the restenosis.
Page 30
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Discussion
• In this case, restenosis in the right EIA was repeated many
times.
• Some treatment options such as balloon angioplasty, stent
deployment, or aspiration were considered at the fifth
recurrence of intermittent claudication. However, the first
two methods could disturb the investigation of the cause
of the restenosis, and the last method could be ineffective.
• Removal of the structure by using a biopsy forceps device
with concurrent viewing under fluoroscopy and IVUS
imaging, which was safely and effectively performed, led
to optimal dilation of the lesion without conventional
angioplasty and diagnosis of the cause of the restenosis.
Page 31
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Discussion
• This patient was an intermediate metabolizer of
CYP2C19.
• Moreover, 50-mg clopidogrel, whicih was less than the
standard dose, was prescribed by her primary care
physician for her had blood disorder.
• The aforementioned factors could possibly induce stent
thrombosis.
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Discussion
• This patient was an intermediate metabolizer of
CYP2C19.
• Moreover, 50-mg clopidogrel, whicih was less than the
standard dose, was prescribed by her primary care
physician for her had blood disorder.
• The aforementioned factors could possibly induce stent
thrombosis.
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Discussion
• This patient was an intermediate metabolizer of
CYP2C19.
• Moreover, 50-mg clopidogrel, whicih was less than the
standard dose, was prescribed by her primary care
physician for her had blood disorder.
• The aforementioned factors could possibly induce stent
thrombosis.
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LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Conclusion
• Endovascular treatment using biopsy forceps was
safe and effective for the restenotic lesion with
an organized thrombus.
• The cause of the stent thrombosis in the present
case might be associated with the intermediate
metabolizer of CYP2C19 and the administration
of low-dose clopidogrel.
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The Fraternity Memorial Hospital
Sumo Stadium
Tokyo Skytree (634 m)
Hokusai’s birth place
and the Sumida Hokusai Museum
Sumida River Fire Works Festival
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Taisuke Sato1, Yasuhiro Takahashi1, Kenta Onodera1 Reiko
Shiomura1, Hiroki Goda1, Isamu Fukuizumi1, Wataru
Shimizu2
1. Department of Cardiology, The Fraternity Memorial Hospital
2. Department of Cardiovascular Medicine, Nippon Medical School
LINC Asia-Pacific 2018 The Fraternity Memorial Hospital
Successful endovascular treatment using
biopsy forceps for iliac artery stenosis with
an organized thrombus