PMC4912498_01
Computed tomography findings. There was no limb stenosis or kinking after endovascular aneurysm repair (dotted line left graft limb, solid line, SMART  stent)
40064_2016_2345_Fig1_HTML.jpg
PMC4912498_01_40064_2016_2345_Fig1_HTML.jpg
Fig1
Computed tomography after EVAR showed no limb stenosis or kinking (Fig. 1).
Photograph of the patient. Ulcers were present on the left leg (arrowheads) 7 months after endovascular aneurysm repair (a knee and lower leg, b ankle, c foot)
40064_2016_2345_Fig2_HTML.jpg
PMC4912498_01_40064_2016_2345_Fig2_HTML.jpg
Fig2
Subsequently, he experienced rest pain and developed ulcers on his left leg; he visited our hospital at the beginning of February 2015 (Fig. 2a-c).
Magnetic resonance angiography findings. A left graft limb occlusion (red arrowheads) and left superficial femoral artery chronic total occlusion (yellow arrowhead) were observed (a pelvic region, b all lower limb regions)
40064_2016_2345_Fig3_HTML.jpg
PMC4912498_01_40064_2016_2345_Fig3_HTML.jpg
Fig3
The deep femoral artery was patent, and it supplied collateral blood flow to the popliteal artery; however, arteries below the knee were totally occluded (Fig. 3a, b).
Initial angiography findings. The left graft limb was totally occluded with a large amount of thrombi (a antegrade angiography, b retrograde angiography)
40064_2016_2345_Fig4_HTML.jpg
PMC4912498_01_40064_2016_2345_Fig4_HTML.jpg
Fig4
Initial angiography showed that the left graft limb was totally occluded with a large amount of thrombi (Fig. 4a, b) and there was severe calcification in the external iliac artery (EIA).
a Angiography findings. The entry of the left limb still seemed narrow after pre-dilatation (arrowhead). b Intravascular ultrasonography findings. The lumen was deformed into a crescent-moon shape. c Intravascular ultrasonography findings. A decrease in the deformation was observed after stent implantation
40064_2016_2345_Fig5_HTML.jpg
PMC4912498_01_40064_2016_2345_Fig5_HTML.jpg
Fig5
Furthermore, the entry of the left limb still seemed narrowed (Fig. 5a). We examined the narrow entry of the left limb by using intravascular ultrasound (IVUS), and we found that the lumen was deformed into a crescent-moon shape (Fig. 5b). After stenting, IVUS showed reduction of the deformation (Fig. 5c).
Angiography findings. Although a small amount of thrombi was found in the left common femoral artery (arrowhead), the final angiography results showed good antegrade flow (a antegrade angiography, b retrograde angiography)
40064_2016_2345_Fig6_HTML.jpg
PMC4912498_01_40064_2016_2345_Fig6_HTML.jpg
Fig6
A small amount of thrombi remained in the left common femoral artery; however, final angiography showed good antegrade flow, and we completed the procedure (Fig. 6a, b).
Angiographic images of endovascular therapy (EVT). EVT for the left superficial femoral artery chronic total occlusion was performed 2 weeks after EVT for the left limb occlusion (a initial angiography, b stenting, c final angiography)
40064_2016_2345_Fig7_HTML.jpg
PMC4912498_01_40064_2016_2345_Fig7_HTML.jpg
Fig7
Two weeks later, the second EVT for the left SFA CTO was performed (Fig. 7a-c).
Computed tomography angiography findings. Good expansion of the two implanted stents was observed. No kink or stenosis was observed in either limb (a the left limb, b the right limb)
40064_2016_2345_Fig8_HTML.jpg
PMC4912498_01_40064_2016_2345_Fig8_HTML.jpg
Fig8
Seven months after the first EVT, the ABI of the left leg improved to 0.96, and computed tomography angiography showed good expansion of the two implanted stents and no kinks or stenosis in either limb (Fig. 8a-b).