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

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

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

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

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

Right EIA After stenting

SMART stent 10.0/60 mmRight proximal EIA occlusion

1st EVT

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

SMART stent 7.0/40 mm

After stenting

2nd EVT

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

PG 35mmHg

NSE PTA 5.0/40 mm

3rd EVT

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

SAVERX 5.0/20 mm

4th EVT

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

PG 57mmHg

• 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

• 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

• 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

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

Angiography

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

IVUS

• 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

• 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

• 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

• 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

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

Strategy

Optimo occlusion catheter

Biopsy forceps

IVUSStructure

Stent

The structure was excised using a biopsy forceps under fluoroscopic

and IVUS image guidance.

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

IVUSFluoroscopy

Procedure

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

Final angiography

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

IVUS

LINC Asia-Pacific 2018 The Fraternity Memorial Hospital

Removed structure

Histological diagnosis: Organized thrombus

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The Fraternity Memorial Hospital

Sumo Stadium

Tokyo Skytree (634 m)

Hokusai’s birth place

and the Sumida Hokusai Museum

Sumida River Fire Works Festival

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