Case report
Retroperitoneal hematoma: An unexpected complication during intervention on an occluded superficial femoral artery via a retrograde popliteal artery approach
Hematoma retroperitoneal: uma complicação inesperada durante intervenção em oclusão de artéria femoral superficial por via retrógrada através de abordagem poplítea
Nuri I. Akkus
, Jagan Beedupalli, Jai Varma
Corresponding author
Department of Cardiology, Louisiana State University Health Sciences Center in Shreveport, Louisiana, LA, USA
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A large aneurysm (arrowheads) is seen at the distal edge of the left main trunk (A1, B1, C1 and C2). The left anterior descending artery (LAD) presents several aneurysms (arrows) but also severe stenotic lesions (resembling a string of beads) with a poor distal bed (A1, B1 and C1). Note the absence of circumflex artery visualization. The ectatic right coronary artery (RCA) also presenting aneurysmal formations (arrows) and obstructive lesions (A2, B2 and C2). A: coronary angiograms of the LAD and RCA. B: curved planar reformation (CPR) in multislice computed tomography (MSCT) of the LAD and RCA. C: Three-dimensional MSCT reconstructions (volume-rendering technique). *: ascending aorta.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eulália Pereira, Bruno Melica, João Primo, João C. Mota, Nuno Ferreira, Gustavo P. 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Morais" ] 6 => array:2 [ "nombre" => "Marta" "apellidos" => "Ponte" ] 7 => array:2 [ "nombre" => "Daniel" "apellidos" => "Caeiro" ] 8 => array:2 [ "nombre" => "Mónica" "apellidos" => "Carvalho" ] 9 => array:2 [ "nombre" => "Nuno" "apellidos" => "Bettencourt" ] 10 => array:2 [ "nombre" => "Luís" "apellidos" => "Vouga" ] 11 => array:2 [ "nombre" => "Vasco" "apellidos" => "Gama" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001578?idApp=UINPBA00004E" "url" => "/21742049/0000003200000078/v1_201310270023/S2174204913001578/v1_201310270023/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2174204913001633" "issn" => "21742049" "doi" => "10.1016/j.repce.2012.11.022" "estado" => "S300" "fechaPublicacion" => "2013-07-01" "aid" => "298" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:619-22" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3890 "formatos" => array:3 [ "EPUB" => 182 "HTML" => 3215 "PDF" => 493 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "An unusual ST-segment elevation: Apical hypertrophic cardiomyopathy shows the ace up its sleeve" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "619" "paginaFinal" => "622" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Elevação do segment St pouco usual: cardiomiopatia hipertrófica apical mostra o às na manga" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2594 "Ancho" => 3000 "Tamanyo" => 841342 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Rest-stress myocardial perfusion scintigraphy revealing reduced left ventricular chamber volume suggestive of hypertrophic cardiomyopathy without signs of ischemia or previous myocardial necrosis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Francesco de Santis, Amedeo Pergolini, Giordano Zampi, Gaetano Pero, Paolo Giuseppe Pino, Giovanni Minardi" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Francesco" "apellidos" => "de Santis" ] 1 => array:2 [ "nombre" => "Amedeo" "apellidos" => "Pergolini" ] 2 => array:2 [ "nombre" => "Giordano" "apellidos" => "Zampi" ] 3 => array:2 [ "nombre" => "Gaetano" "apellidos" => "Pero" ] 4 => array:2 [ "nombre" => "Paolo Giuseppe" "apellidos" => "Pino" ] 5 => array:2 [ "nombre" => "Giovanni" "apellidos" => "Minardi" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001633?idApp=UINPBA00004E" "url" => "/21742049/0000003200000078/v1_201310270023/S2174204913001633/v1_201310270023/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Retroperitoneal hematoma: An unexpected complication during intervention on an occluded superficial femoral artery via a retrograde popliteal artery approach" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "623" "paginaFinal" => "627" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Nuri I. Akkus, Jagan Beedupalli, Jai Varma" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Nuri I." "apellidos" => "Akkus" "email" => array:1 [ 0 => "iakkus@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Jagan" "apellidos" => "Beedupalli" ] 2 => array:2 [ "nombre" => "Jai" "apellidos" => "Varma" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Cardiology, Louisiana State University Health Sciences Center in Shreveport, Louisiana, LA, USA" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Hematoma retroperitoneal: uma complicação inesperada durante intervenção em oclusão de artéria femoral superficial por via retrógrada através de abordagem poplítea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 112241 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Angiogram showing the sheath in the common femoral artery showing the profunda femoris (large arrow). The SFA is occluded at the origin (small arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The prevalence of peripheral arterial disease is increasing worldwide due to increase in life expectancy, obesity and diabetes.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Symptomatic atherosclerosis of the lower extremity arteries commonly involves the superficial femoral artery (SFA) and is characterized by long, diffuse lesions and long total occlusions.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Endovascular therapy has seen major advances in the last decade with the introduction of several new techniques and devices.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Retrograde popliteal access has been proposed as a safe and effective means to increase the success rate of percutaneous transluminal angioplasty (PTA) for SFA occlusions after a failed antegrade attempt by means of ipsilateral or contralateral femoral access.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The rationale for this increased success rate is that the distal occlusion stump in this vessel, as in others, is usually tapered, thereby increasing the likelihood of intraluminal seating of guidewires.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a> However, the retrograde popliteal approach to SFA occlusions is a relatively new technique and there have been few reports concerning complications with this approach.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report a case of attempted angioplasty of a CTO of the left SFA through a retrograde ipsilateral popliteal approach that was complicated by dissection and perforation causing retroperitoneal bleeding, and the management strategy successfully used to control the bleeding.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 50-year-old Caucasian woman with hypertension, tobacco abuse, and peripheral arterial disease with life-limiting claudication had stents placed in bilateral 80% ostial iliac artery lesions two months previously. She was also noted to have a CTO of the left SFA at the ostium with no obvious stump (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) which was reconstituting distally via collaterals just above the popliteal artery (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>). Due to her ongoing symptoms despite optimal medical therapy, it was decided to intervene on the SFA. Since there was no obvious stump of the occluded SFA proximally, we decided to approach the CTO through a retrograde approach.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A 4F sheath was first placed into the left femoral artery with the patient supine, and then the patient was placed in a prone position. After obtaining an angiogram of the left lower extremity, the popliteal artery was accessed under fluoroscopic guidance and a short 6-cm 6F sheath was placed. After adequate anticoagulation was achieved with heparin, a Confianza pro 12 wire (Asahi Intecc, Nagoya, Japan) was used to cross the CTO with support from a Trailblazer support catheter (ev3, Plymouth, MN), which appeared to be in the true lumen of the SFA until the proximal to ostial SFA, from where it went into multiple dissection planes. Then, the Confianza pro 12 wire was replaced by a 0.035 Glidewire Advantage wire (Terumo Interventional Systems, Somerset, NJ), which also went to different dissection planes; there was a collateral vessel at the proximal SFA extending to the external iliac artery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">An angiogram from the left femoral sheath at this time showed retrograde filling of the distal and proximal SFA (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>) and then the dissection plane in the EIA with a wire tip perforation and bleeding (<a class="elsevierStyleCrossRefs" href="#fig0025">Figures 5 and 6</a>) to the retroperitoneal region at the external iliac artery with displaced bladder (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>). Protamine was given to reverse the heparin and a 7-minute balloon inflation was performed in the distal SFA using a 5.0 mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40 mm Evercross balloon (ev3, Plymouth, MN) to stop the retrograde bleeding. On repeat angiography, the distal SFA CTO was reoccluded and the dissection plane appeared to be sealed, with no further bleeding into the retroperitoneal region (<a class="elsevierStyleCrossRefs" href="#fig0035">Figures 7 and 8</a>). Other than mild nausea after protamine, the patient reported no major symptoms during this procedure. When activated coagulation time was 130 s, the femoral and popliteal sheaths were removed. A 3-g/dl drop in hemoglobin was noted after the procedure that remained stable over the next two days. Popliteal and pedal pulses were palpable and unchanged following the procedure.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">A retrograde popliteal approach to SFA occlusions was first described by Tonnesen et al. in 1988.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Since then, this approach has proved a useful alternative for angioplasty of some SFA occlusions, indications being occlusion of the SFA origin, adverse collateral anatomy, and other difficulties in obtaining access to the common femoral artery.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Complications involving this approach are usually infrequent according to prior reports.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6,10–12</span></a> Since this approach has been increasingly used recently and little is known about potential complications during this procedure, we decided to report our experience and the management strategies we adopted in treating the complications described. Retrograde dissections and perforation during a popliteal approach may be benign when there is no retrograde flow, but as seen in our case, after wiring and advancement of support catheters inside the CTO retrograde flow can be established, especially with a partially obstructive popliteal sheath and lack of antegrade flow from the proximal end of the occlusion. In the case reported, if we had been able to establish antegrade flow by accessing the true lumen proximally, we could also have stopped the retrograde filling. During all this time the patient was in a prone position and the balloon was advanced through the popliteal sheath and inflated at the distal SFA to stop retrograde filling. The other option could have been to turn the patient to a supine position and to inflate the balloon in the proximal EIA, stopping the blood flow to the profunda femoris and collaterals to the popliteal and subsequently to the dissection plane. This approach would have taken longer and would have been physically more difficult for the patient.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Our case report illustrates a dangerous complication that can occur during an intervention on an occluded SFA via a popliteal approach when the artery is partially recanalized and retrograde flow is present. Occasional cine angiograms after wiring the lesion (especially if there is any sign of bladder displacement) and once the presence of retrograde flow is established avoiding wires that may increase the chance of perforations, staying below the common femoral artery level, may decrease the risk of retroperitoneal hematoma. Balloon positioning and inflation at the distal SFA through the popliteal sheath will effectively stop the retrograde filling and can be used in such cases in the absence of antegrade filling of the perforation.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres286545" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec269730" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres286546" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec269729" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-11-01" "fechaAceptado" => "2012-11-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec269730" "palabras" => array:4 [ 0 => "Peripheral vascular disease" 1 => "Superficial femoral artery" 2 => "Popliteal approach" 3 => "Retroperitoneal hematoma" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec269729" "palabras" => array:4 [ 0 => "Doença arterial periférica" 1 => "Artéria femoral superficial" 2 => "Acesso poplíteo" 3 => "Hematoma retroperitoneal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Peripheral arterial disease involvement of the superficial femoral artery (SFA) is common. Different endovascular techniques are used successfully for revascularization of this artery. A retrograde approach to chronic total occlusion (CTO) of the SFA through the ipsilateral popliteal artery has been used occasionally if an antegrade approach is not feasible or has failed. Some of the known complications encountered during this approach are arteriovenous fistula formation at the access site, occlusion of the popliteal artery if closure devices are used, and bleeding. There are no reports of perforation or bleeding of the SFA or the external iliac artery (EIA) during a popliteal approach, probably due to lack of flow in the occluded segment of the SFA. We report a case in which a retroperitoneal hematoma occurred due to retrograde blood flow through the established true channel in the proximal SFA and subsequently to the dissection plane with a wire tip perforation in the EIA, which was treated by stopping retrograde filling with prolonged balloon inflation in the distal SFA before the CTO.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O envolvimento da artéria femoral superficial (AFS) na doença arterial periférica é comum. Existem diversas técnicas endovasculares usadas com sucesso para a revascularização desta artéria. A abordagem retrógrada da oclusão total crónica (OTC) da AFS através da artéria poplítea ipsilateral tem sido usada ocasionalmente quando a abordagem anterógrada não é possível ou após tentativa anterógrada falhada. Algumas das complicações conhecidas encontradas durante esta abordagem são a formação de fístula arteriovenosa no local do acesso, oclusão da artéria poplítea se se utilizam dispositivos de encerramento e hemorragia. Não estão descritos perfuração ou sangramento da AFS ou da artéria ilíaca externa (AIE) durante a abordagem poplítea, provavelmente devido à falta de fluxo no segmento ocluído da AFS. Aqui reportamos um caso em que ocorreu um hematoma retroperitoneal devido ao fluxo sanguíneo retrógrado através do verdadeiro canal estabelecido na AFS proximal e em consequência de plano de dissecção e perfuração com a ponta do fio-guia na AIE e o seu tratamento por paragem do preenchimento retrógrado através de insuflação de balão prolongada na AFS distal, antes da OTC.</p>" ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 112241 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Angiogram showing the sheath in the common femoral artery showing the profunda femoris (large arrow). The SFA is occluded at the origin (small arrow).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 119168 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Angiogram showing filling of the distal superficial femoral artery via collaterals from the profunda femoris (large arrow) with the distal occlusion stump (small arrow).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 132667 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Angiogram showing the popliteal artery (large arrow) and collateral feeding the distal SFA and popliteal artery (small arrow).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 116368 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Angiography through the common femoral artery sheath showing the collateral to the SFA (short arrow) and retrograde filling of the distal and mid SFA (long arrow) after wiring the SFA occlusion via a retrograde popliteal approach.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 127239 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Angiogram showing retrograde filling of the proximal superficial femoral artery (SFA), collateral to the SFA (white arrow) and dissection plane in the external iliac artery (short arrow) with perforation into the retroperitoneal space (long arrow).</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 119874 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Angiogram showing perforation (long arrow) from the dissection plane in the external iliac artery causing retroperitoneal bleeding as evidenced by displacement of the urinary bladder (short arrow). Also shown is the ureter (white arrow).</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 112361 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Angiogram showing no retrograde flow in the distal SFA.</p>" ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 122800 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Angiogram of the ipsilateral common femoral sheath showing sealed perforation (arrow) and closed dissection plane after prolonged balloon inflation in the distal popliteal artery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of peripheral arterial disease patients: comparing the ACC/AHA and TASC-II guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 4 | 12 |
| 2024 October | 59 | 33 | 92 |
| 2024 September | 70 | 26 | 96 |
| 2024 August | 74 | 29 | 103 |
| 2024 July | 52 | 33 | 85 |
| 2024 June | 44 | 28 | 72 |
| 2024 May | 54 | 28 | 82 |
| 2024 April | 54 | 31 | 85 |
| 2024 March | 53 | 18 | 71 |
| 2024 February | 39 | 18 | 57 |
| 2024 January | 40 | 31 | 71 |
| 2023 December | 42 | 25 | 67 |
| 2023 November | 48 | 24 | 72 |
| 2023 October | 43 | 17 | 60 |
| 2023 September | 43 | 27 | 70 |
| 2023 August | 53 | 16 | 69 |
| 2023 July | 58 | 8 | 66 |
| 2023 June | 55 | 20 | 75 |
| 2023 May | 57 | 20 | 77 |
| 2023 April | 40 | 5 | 45 |
| 2023 March | 56 | 18 | 74 |
| 2023 February | 46 | 24 | 70 |
| 2023 January | 39 | 11 | 50 |
| 2022 December | 58 | 21 | 79 |
| 2022 November | 62 | 26 | 88 |
| 2022 October | 41 | 13 | 54 |
| 2022 September | 48 | 30 | 78 |
| 2022 August | 56 | 36 | 92 |
| 2022 July | 59 | 35 | 94 |
| 2022 June | 43 | 28 | 71 |
| 2022 May | 46 | 27 | 73 |
| 2022 April | 57 | 21 | 78 |
| 2022 March | 58 | 31 | 89 |
| 2022 February | 72 | 20 | 92 |
| 2022 January | 100 | 23 | 123 |
| 2021 December | 46 | 36 | 82 |
| 2021 November | 59 | 36 | 95 |
| 2021 October | 99 | 37 | 136 |
| 2021 September | 50 | 30 | 80 |
| 2021 August | 59 | 36 | 95 |
| 2021 July | 59 | 35 | 94 |
| 2021 June | 42 | 20 | 62 |
| 2021 May | 56 | 39 | 95 |
| 2021 April | 105 | 37 | 142 |
| 2021 March | 93 | 12 | 105 |
| 2021 February | 99 | 22 | 121 |
| 2021 January | 50 | 12 | 62 |
| 2020 December | 47 | 10 | 57 |
| 2020 November | 47 | 20 | 67 |
| 2020 October | 48 | 19 | 67 |
| 2020 September | 71 | 15 | 86 |
| 2020 August | 50 | 10 | 60 |
| 2020 July | 76 | 13 | 89 |
| 2020 June | 50 | 7 | 57 |
| 2020 May | 81 | 10 | 91 |
| 2020 April | 72 | 12 | 84 |
| 2020 March | 69 | 17 | 86 |
| 2020 February | 158 | 19 | 177 |
| 2020 January | 55 | 9 | 64 |
| 2019 December | 59 | 12 | 71 |
| 2019 November | 115 | 10 | 125 |
| 2019 October | 66 | 9 | 75 |
| 2019 September | 111 | 10 | 121 |
| 2019 August | 51 | 3 | 54 |
| 2019 July | 43 | 14 | 57 |
| 2019 June | 107 | 8 | 115 |
| 2019 May | 108 | 14 | 122 |
| 2019 April | 88 | 16 | 104 |
| 2019 March | 111 | 8 | 119 |
| 2019 February | 127 | 10 | 137 |
| 2019 January | 76 | 6 | 82 |
| 2018 December | 113 | 9 | 122 |
| 2018 November | 183 | 5 | 188 |
| 2018 October | 249 | 14 | 263 |
| 2018 September | 85 | 11 | 96 |
| 2018 August | 65 | 9 | 74 |
| 2018 July | 55 | 3 | 58 |
| 2018 June | 80 | 7 | 87 |
| 2018 May | 59 | 4 | 63 |
| 2018 April | 35 | 5 | 40 |
| 2018 March | 59 | 4 | 63 |
| 2018 February | 34 | 5 | 39 |
| 2018 January | 38 | 5 | 43 |
| 2017 December | 59 | 1 | 60 |
| 2017 November | 34 | 9 | 43 |
| 2017 October | 30 | 11 | 41 |
| 2017 September | 38 | 9 | 47 |
| 2017 August | 38 | 11 | 49 |
| 2017 July | 30 | 13 | 43 |
| 2017 June | 47 | 7 | 54 |
| 2017 May | 48 | 6 | 54 |
| 2017 April | 28 | 3 | 31 |
| 2017 March | 57 | 9 | 66 |
| 2017 February | 57 | 3 | 60 |
| 2017 January | 50 | 1 | 51 |
| 2016 December | 61 | 9 | 70 |
| 2016 November | 51 | 5 | 56 |
| 2016 October | 58 | 5 | 63 |
| 2016 September | 89 | 8 | 97 |
| 2016 August | 32 | 2 | 34 |
| 2016 July | 26 | 2 | 28 |
| 2016 June | 35 | 3 | 38 |
| 2016 May | 44 | 3 | 47 |
| 2016 April | 31 | 1 | 32 |
| 2016 March | 43 | 5 | 48 |
| 2016 February | 65 | 13 | 78 |
| 2016 January | 41 | 9 | 50 |
| 2015 December | 34 | 5 | 39 |
| 2015 November | 39 | 3 | 42 |
| 2015 October | 50 | 4 | 54 |
| 2015 September | 63 | 11 | 74 |
| 2015 August | 37 | 3 | 40 |
| 2015 July | 28 | 6 | 34 |
| 2015 June | 14 | 2 | 16 |
| 2015 May | 25 | 5 | 30 |
| 2015 April | 29 | 8 | 37 |
| 2015 March | 24 | 9 | 33 |
| 2015 February | 22 | 6 | 28 |
| 2015 January | 30 | 5 | 35 |
| 2014 December | 37 | 9 | 46 |
| 2014 November | 33 | 7 | 40 |
| 2014 October | 44 | 4 | 48 |
| 2014 September | 42 | 8 | 50 |
| 2014 August | 36 | 7 | 43 |
| 2014 July | 44 | 10 | 54 |
| 2014 June | 35 | 7 | 42 |
| 2014 May | 35 | 11 | 46 |
| 2014 April | 33 | 4 | 37 |
| 2014 March | 48 | 11 | 59 |
| 2014 February | 53 | 12 | 65 |
| 2014 January | 48 | 12 | 60 |
| 2013 December | 47 | 10 | 57 |
| 2013 November | 56 | 7 | 63 |
| 2013 October | 4 | 2 | 6 |
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