Caput Medusa: A Critical Limb Ischemia Conundrum

Purpose: Peripheral artery disease is a growing pandemic, with a prevalence higher than ischemic heart disease and cancer combined. Critical limb ischemia, the deadliest form of the disease, is usually associated with infrapopliteal artery disease. We present a case requiring multiple innovative techniques.

Materials and Methods: A 61-year-old man presented with chronic leg pain and swelling. Ankle-brachial index (ABI) demonstrated distal bilateral leg atherosclerotic disease; right ABI measured 0.8, and ABI left was 0.6. Bilateral arterial ultrasonography showed biphasic flow in the profunda and superficial femoral artery (SFA) with elevated velocities in the distal SFA.

Results: Given the lack of iliac disease and significant below-the-knee disease, anterograde puncture of the right common femoral artery (CFA) was obtained. Digital subtraction angiography was performed, confirming a calcified stump occlusion at the level of the popliteal artery. Reconstitution of the anterior tibial and posterior tibial arteries was noted at the level of the ankle. To avoid injury, a primary retrograde approach was chosen. Ultrasound-guided dorsalis pedis access was obtained, and a 4-Fr sheath was inserted. A V 18 wire and a CXI 0.018 90-cm support catheter were used to cross the occluded anterior tibial artery using the JENALI technique. A Navicross 0.035 90-cm catheter was placed from above in the popliteal artery. The 0.018 wire and catheter were advanced into the 0.035 catheter. A 0.14 wire was then placed (flossed), and both support catheters were removed. Intravascular ultrasound (IVUS) was done for vessel sizing, evaluation of plaque morphology, and confirmation of intraluminal crossing. Orbital atherectomy was chosen because of severe calcification. Sequential angioplasty yielded excellent results. The patient was brought back because of nonresolution of symptoms. A right CFA with anterograde access was obtained. A favorable stump of the tibioperoneal trunk was noted, prompting an attempt of anterograde wiring using a combination of a Command ES 0.014 wire and a Navicross 0.035 support catheter, which was successful. IVUS followed by sequential angioplasty was performed. Final results with two-vessel run were obtained, and the patient had resolution of his pain at rest.

Conclusions: The increased prevalence of diabetes and peripheral vascular disease mandates that vascular operators continue to find innovative solutions for treating patients with advanced disease.