Arterial Occlusion Caused by Intimal Flap Elevation After Arteriosclerosis Obliterans Stent Implantation: A Case Report

ABSTRACT

Stent‐related dissection is a well‐recognized complication of endovascular intervention. However, acute arterial occlusion resulting from stent‐induced intimal flap displacement at a major bifurcation is rare and carries a high risk of limb‐threatening ischemia. We present the case of an 84‐year‐old female with multilevel lower extremity atherosclerotic disease, complicated by diabetes and hypertension, who presented with bilateral ischemic foot ulcers. During endovascular revascularization, iatrogenic intimal flap prolapse at the tibioperoneal trunk led to acute occlusion of the peroneal artery. Successful restoration of distal flow was achieved through retrograde puncture followed by balloon angioplasty. Final angiography demonstrated optimal distal perfusion with no residual stenosis. This case underscores the necessity of prompt intraoperative identification and the strategic application of salvage techniques to manage complex mechanical complications during distal revascularization.

Key Clinical Message

Stent‐induced intimal flap displacement leading to acute peroneal artery occlusion represents a rare yet critical mechanical complication during distal revascularization. Retrograde access provides a decisive salvage pathway when antegrade maneuvers fail, facilitating successful recanalization and ensuring optimal limb salvage outcomes.

1. Introduction

Iatrogenic arterial dissection remains a well‐documented complication of endovascular revascularization, frequently occurring during high‐pressure balloon angioplasty or stent deployment. While the majority of these dissections are stabilized by stent scaffolding, the mechanical displacement of an intimal flap can occasionally lead to acute luminal occlusion and critical distal ischemia. This complication is particularly detrimental in patients with chronic limb‐threatening ischemia (CLTI), where the preservation of every outflow vessel is vital for limb salvage. We present a case of stent‐induced intimal flap prolapse at the tibioperoneal trunk resulting in acute peroneal artery occlusion. Following the technical failure of antegrade maneuvers, a retrograde endovascular salvage strategy was successfully employed to restore arterial patency and distal perfusion.

2. Case Presentation and Clinical Examination

An 84‐year‐old female presented with a 7‐month history of bilateral, refractory foot ulcers. Physical examination revealed diminished skin temperature in both feet and bilateral dorsal edema. The right hallux exhibited a purulent ulcer, while the left heel presented a more extensive ulcer bed characterized by yellowish necrotic tissue, purulent exudate, and liquefaction of subcutaneous fat.

The patient had a history of hypertension and diabetes mellitus. Bilateral foot ulcers first appeared 7 months prior to admission, followed by progressive ischemic pain in both lower extremities. Four months before the current presentation, she was hospitalized for conservative management, which included traditional Chinese medicine and specialized wound care; however, these interventions yielded only transient clinical improvement. Computed tomography angiography (CTA) subsequently confirmed multilevel atherosclerotic changes consistent with lower extremity atherosclerotic occlusive disease (LEAD).

3. Differential Diagnosis, Investigations and Treatment

Lower extremity CTA demonstrated diffuse and complex atherosclerotic lesions. The bilateral femoral arteries exhibited segmental occlusions with collateralization, involving mixed‐to‐soft plaques and moderate‐to‐severe stenosis. Similar findings, including segmental occlusion and surrounding collateral circulation, were observed in the left popliteal artery. Distally, the bilateral anterior tibial, posterior tibial, and peroneal arteries showed severe stenosis with compromised distal filling.

Based on the findings, endovascular intervention was performed under local anesthesia. Sequential balloon angioplasty from the peroneal artery to the superficial femoral artery (SFA) was performed using a Saber balloon (2.5–4.0 mm), followed by dilation of the popliteal artery P2 segment with a 5 × 100 mm balloon. A Supera 4.5 × 120 mm stent was then deployed from the popliteal artery P3 segment to the SFA. Angiography showed stent patency and improved anterior tibial artery (ATA) perfusion; however, the peroneal artery was no longer visualized (Figure 1).

FIGURE 1.

Preoperative computed tomography angiography (CTA) showing lower extremity arterial lesions.

This suggested that an iatrogenic intimal flap at the popliteal‐tibioperoneal junction had been displaced by the stent, occluding the peroneal artery orifice. After antegrade attempts to cross the lesion were unsuccessful, a retrograde approach was performed. The distal peroneal artery was punctured under ultrasound guidance using a micropuncture needle. After access was established, a 0.018‐in. support catheter and guidewire were advanced retrogradely into the Supera stent and externalized through the proximal sheath while maintaining wire position in the ATA.

Balloon angioplasty was then performed using a Saber 3.0 × 150 mm balloon from the peroneal artery to the popliteal artery. To ensure adequate inflow, two SmartFlex 3.0 × 150 mm stents were implanted to connect the Supera stent to the proximal segments. Following post‐dilation with a 5 × 100 mm balloon, final angiography confirmed stent expansion and patency of all distal runoff vessels.

4. Outcome and Follow‐Up

Postoperatively, the patient was maintained on a medical regimen of beraprost sodium (40 μg three times daily), sarpogrelate (100 mg three times daily), and aspirin (100 mg once daily). Wound management included regular debridement and vacuum sealing drainage (VSD) therapy. At the 3‐month follow‐up, clinical improvement was observed, with significant enhancement in limb perfusion and satisfactory wound healing (Figures 2 and 3).

FIGURE 2.

Intraoperative angiographic findings and procedural steps. (A) Angiography before stent placement. (B) Popliteal artery stent deployment. (C) Retrograde access via the distal peroneal artery. (D) Restoration of flow after balloon angioplasty. (E) Proximal stent implantation. (F) Final angiography demonstrating satisfactory vessel patency.

FIGURE 3.

Endovascular procedural workflow illustrating the management of peroneal artery occlusion caused by intimal flap formation following popliteal artery stent deployment.

5. Discussion

Arterial dissection is a recognized complication of endovascular revascularization, primarily driven by mechanical barotrauma and compliance mismatch between the metallic stent and the native arterial wall [1]. The structural separation of the intima from the media can lead to false lumen formation and disrupted laminar flow, which subsequently triggers a pro‐thrombotic cascade involving platelet activation and neointimal hyperplasia [2]. These hemodynamic and biological disturbances synergistically increase the risk of restenosis and adverse limb events.

Most such dissections are effectively managed through stent implantation, which apposes the intimal flap against the vessel wall to restore luminal integrity and maintain vessel patency [3]. While stenting remains an effective remedy, the frequent occurrence of these events underscores the need to identify potential risk factors and procedural determinants.

While stent implantation provides structural support, the interplay between stent architecture and vascular biology is critical. Biomechanical forces such as friction and compression can acutely compromise endothelial integrity [4]. Specifically, woven nitinol designs—while offering high radial strength—may exert heterogeneous chronic inward force, particularly in curved segments like the popliteal artery [5]. Suboptimal stent sizing, especially oversizing, increases the risk of iatrogenic dissection by creating localized high‐stress concentrations that exceed the vessel's mechanical threshold [6].

Stent deployment fundamentally alters the mechanical loading state of the arterial wall [7]. This shift is characterized by low wall shear stress (WSS) and elevated oscillatory shear indices, which are further exacerbated by non‐laminar flow around the displaced intimal flap [7]. These biomechanical cues trigger mechanotransduction pathways that drive endothelial‐to‐mesenchymal transition (EndoMT) [8, 9, 10]. In this state, ECs lose their polarity and adopt a secretory phenotype, promoting maladaptive remodeling and potentially compromising the long‐term stability of the revascularized segment.

The selection of anesthetic modality influences intraoperative risk and clinical outcomes. Current evidence suggests no significant difference in major adverse event rates between local anesthesia (LA) and general anesthesia (GA) [11]. GA offers advantages in patient immobilization and imaging quality, which may facilitate technical success during complex interventions. However, these benefits are accompanied by a higher incidence of hemodynamic instability and respiratory complications [12, 13]. Drawing from experience in transcatheter aortic valve replacement (TAVR), optimizing anesthesia is critical to enhancing outcomes, as hemodynamic stability and precise perioperative management directly influence the success of valve‐like mechanical interventions [14]. Given the comparable long‐term outcomes, the choice of anesthesia depends on clinical judgment and patient‐specific requirements.

Beyond intraoperative techniques, perioperative variables such as systemic inflammatory status and plaque vulnerability dictate the arterial wall's structural resilience. Pro‐inflammatory states may downregulate matrix‐stabilizing proteins, lowering the threshold for mechanical failure during endovascular maneuvers. Therefore, a mechanistically informed approach that integrates these considerations is necessary to mitigate iatrogenic risks and broaden the safety margin of complex interventions. Intimal flap elevation after stent deployment is therefore a rare but potentially hazardous intraoperative complication that requires careful management.

Maintaining distal perfusion is essential for patients with chronic limb‐threatening ischemia (CLTI). Revascularization of infrapopliteal and tibial arteries is critical for limb salvage, especially in cases involving ischemic ulcers or tissue loss [15]. Long‐term clinical data demonstrate that successful endovascular interventions correlate with improved wound healing and higher rates of limb preservation [16]. Establishing inline flow to the distal run‐off reduces the risk of major amputation and adverse limb events. Consequently, procedural complications that compromise below‐the‐knee perfusion require prompt recognition and effective management.

In this context, the present case demonstrates the management of a critical inflow obstruction during popliteal intervention. In the present case, the valve‐like mechanism of the displaced intimal flap following stenting resulted in acute peroneal artery occlusion. While antegrade attempts failed due to the flap's orientation and rigidity, retrograde access provided a critical alternative vector to re‐enter the true lumen of the Supera stent. This underscores that while prevention through vessel preparation is paramount, the capacity for prompt technical resolution through versatile salvage maneuvers remains indispensable for limb salvage (Figure 4).

FIGURE 4.

Schematic illustration of lower limb arterial anatomy showing intimal flap formation at the popliteal–tibioperoneal junction resulting in occlusion of the peroneal artery.

Strategies to prevent intraoperative dissection should address device selection, sizing accuracy, and dilation techniques. Utilizing constrained expansion balloons during vessel preparation effectively reduces the incidence of flow‐limiting dissections and the requirement for bailout stenting compared to conventional angioplasty [17]. Precise vessel diameter measurement via pre‐procedural imaging is essential to control the balloon‐to‐vessel ratio and avoid overexpansion, as inappropriate sizing is a primary risk factor for severe dissection [7]. Furthermore, a stepwise incremental dilation strategy should be adopted for calcified or chronic total occlusion lesions, initiating treatment with small‐diameter balloons at low pressures to minimize intimal trauma. Finally, the “leave nothing behind” philosophy remains a priority, reserving stent implantation for severe complications while utilizing drug‐coated balloons as the preferred modality for non‐flow‐limiting dissections [18].

Specialty devices such as scoring and cutting balloons facilitate controlled plaque modification and reduce the risk of erratic dissections associated with standard angioplasty [19]. In more challenging calcified segments, intravascular lithotripsy (IVL) uses acoustic shockwaves to fracture medial and intimal calcium. This mechanism improves vessel compliance and allows for predictable luminal gain without the barotrauma typical of high‐pressure inflation [20]. These adjunct technologies offer a safer alternative for managing complex arterial anatomy.

Collectively, these strategies and adjunct technologies provide a safer alternative for managing complex arterial anatomy. As illustrated in the present case, while prevention is paramount, the capacity for prompt technical resolution remains indispensable—specifically utilizing retrograde access to overcome the valve‐like resistance of a rigid intimal flap. This alternative vector allows for successful true lumen re‐entry when antegrade maneuvers are physically impeded. Ultimately, intraoperative vigilance and a versatile salvage repertoire are crucial for managing mechanical failures and ensuring optimal limb salvage outcomes in distal revascularization.

Author Contributions

Le Zhang: writing – original draft. Feng Lu: conceptualization, data curation. Kangli Yin: methodology. Yudong Fang: supervision. Jian Dong: funding acquisition, project administration, resources.

Funding

This work was supported by grants from the following funding sources: The Clinical Key Specialty Construction Project of the Hongkou District Health Commission of Shanghai (Grant No. HKLKFC202401), The Shanghai “Oriental Talent” Program (Grant No. QNWS2024018), The Key Special Project of the Hongkou District Health Commission of Shanghai (Grant No. Hong Wei 2201–05), The Talent Training Project of the Hongkou District Health Commission of Shanghai (Grant No. HKLCYQ2024‐11), and the General Project of the Hongkou District Health Commission of Shanghai (Grant No. Hong Wei 2202–26).

Ethics Statement

Written informed consent for publication was obtained from the patient. The study protocol was approved by the Institutional Ethics Committee of Shanghai TCM‐Integrated Hospital, Shanghai University of Traditional Chinese Medicine (Approval No. 2024‐019‐01).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data supporting the findings of this study are available within the article.