Successful Implantation of a Coronary Stent Graft in a Peripheral Vessel

Peripheral artery disease (PAD) is a complex, often underdiagnosed illness with rising prevalence in western world countries. During the past decade there has been a rapid advance especially in the field of endovascular treatment of PAD. Here we present for the first time a case reporting on the placement of coronary stent graft in a peripheral vessel for the management of a peripheral side branch perforation. Interventional angiologists or radiologists may consider such an option for complication management after injury of smaller vessels during peripheral percutaneous interventions. Further specialization and novel options of complication management as described in our case may shift the treatment from surgical to even more endovascular treatment procedures in the future.


Introduction
Peripheral artery disease (PAD) is a complex, often underdiagnosed illness with rising prevalence in western world countries [1]. Patients suffering from PAD present with a broad spectrum of symptoms ranging from asymptomatic vascular disease over intermittent claudication to critical limb ischemia (CLI). The overall life expectancy of patients with symptomatic PAD is 80% during 5 years of follow-up [2,3]. CLI has a significant worse prognosis with an amputation rate of 14-20% and a death rate of 25% within the first year after diagnosis and 50% within five years [4].
Treatment of PAD involves life style modification (e.g., smoking cessation and physical exercise), consequent risk factor control (e.g., statin use), antithrombotic treatment, and endovascular or surgical revascularization. During the past decade there has been a rapid advance especially in the field of endovascular treatment of PAD, contributing to significant reduction of symptoms and improvement of outcomes in such patients. Thus, the number of major amputations decreases, with increasing rates of successful endovascular procedures within the last decade [5]. The recent ERASE study [6], on the other hand, showed that combining endovascular revascularization with supervised exercise training resulted in substantial improvement of clinical symptoms in patients with intermittent claudication. Despite all these technical advances with endovascular treatment option, complications during such procedures may still occur and their appropriate management remains a challenge for clinicians. One of the most feared complications is bleeding, which can lead to large painful hematoma or even to compartment syndrome.

Case Presentation
An 88-year-old patient suffering from Fontaine stage IIb peripheral artery disease of his left leg was referred for interventional treatment in our angiology department. Using digital subtraction angiography (DSA) high grade lesions were identified in both his left common iliac and left superficial femoral artery, which were treated by percutaneous transluminal angioplasty (PTA) and placement of a bare metal (12 * 40 mm Dynamic, Biotronik, Berlin, Germany) stent and by drug-eluting PTA (6.0 * 120 mm, INPACT Admiral, Medtronic, Minneapolis, USA), respectively, using a 0.035 Terumo Stiff hydrophilic guide wire (Figures 1(a)-1(d)). A minor not flow-limiting dissection was treated with DEB to Our patient could be directly mobilized 4 hours after the intervention and did not report any local pain, paraesthesia, or intermittent claudication. Using colour doppler ultrasound the stent graft could be visualized one day after implantation, exhibiting normal blood flow. No signs of haematoma or other bleeding complications could be visualized by ultrasonography (Figures 2(e) and 2(f)).

Discussion
To our knowledge this is the first case reporting on the placement of coronary stent graft in a peripheral vessel for the management of a peripheral side branch perforation. Interventional angiologists or radiologists may consider such an option for complication management after injury of smaller vessels during peripheral percutaneous interventions.
In the past years significant technical developments have occurred with endovascular therapy, which offer several distinct advantages over open surgical revascularization techniques in selected lesions [7]. Further specialization and novel options of complication management as described in our case may shift the treatment from surgical to even more endovascular treatment procedures in the future.