Treating Complex Multi-Level, Multi-Vessel CLI Requires a Complex, Multi-Disciplinary Approach

History and Background

A 52-year-old black female, former smoker, with a seven-year history of type II diabetes, sought a second opinion at the authors’ institution. Her story began 4 months earlier when skin and temperature changes to her left foot were eventually diagnosed to be related to peripheral artery disease (PAD) and critical limb ischemia (CLI). She underwent bilateral aortoiliac percutaneous transluminal angioplasty (PTA)/stent at the outside institution, complicated by atheroemboli to the left lower extremity, thus resulting in the development of left foot ulceration and gangrene. Left distal popliteal to tibial bypass was performed but unfortunately occluded within weeks. Due to the progression of her distal foot ulceration/gangrene, transmetatarsal amputation (TMA) was performed. Following amputation, hyperbaric oxygen (HBO) therapy was initiated to aid in surgical wound healing. Her medical therapy included warfarin and aspirin in addition to her diabetic regime. Despite these aforementioned efforts, the TMA site as well as the distal bypass anastomosis incision site did not show appropriate healing, and she was scheduled to undergo left below-the-knee amputation (BKA). 

Presentation

The patient’s first presentation to the authors’ institution was via the emergency department with a Rutherford Class 6 ulcer. Initial non-invasive diagnostic evaluations were performed, followed by diagnostic angiography with plans for left lower extremity (LLE) endovascular intervention. Of note, her hemoglobin was noted to be 9.0 on admission and dropped to 7.9 after diagnostic angiography.  

Diagnostic angiography of the left lower extremity revealed a 100% occlusion of the left popliteal/posterior tibial bypass, a 150mm, 100% occlusion of the left mid anterior tibial artery without reconstitution, and a 300mm, 100% occlusion of the left posterior tibial artery. Incidentally, the right common iliac artery stent was also noted to be fully occluded (Figure 1A-F).

Treatment

The patient was transfused 1 unit of packed red blood cells (PRBCs) prior to revascularization. Utilizing extravascular ultrasound, access of the left common femoral, posterior tibial, and anterior tibial arteries were performed, allowing the endovascular interventions below (Figure 2A-C):

• Excimer laser (Spectranetics) atherectomy of the left anterior tibial, posterior tibial, and lateral plantar arteries;
• PTA of the dorsalis pedis, anterior tibial, lateral plantar, and posterior tibial arteries;
• AngioJet (Boston Scientific) thrombectomy of the lateral plantar and posterior tibial arteries.

Revascularization resulted in excellent flow to the foot with bleeding noted at the TMA site. Hemoglobin improved and vital signs were stable. The patient was discharged the next day and received a revised TMA with implantation of antibiotic beads two days later. 

Regression of Wound Healing and Repeat Endovascular Revascularization

Wound healing was initially appropriate. However, three weeks later, there was delay in the progress of healing and the wound care specialist referred her back for further arterial evaluation. At this point, arterial insufficiency was confirmed to be the cause of delayed wound healing. Diagnostic angiography was performed with an anticipated need for repeat endovascular intervention. The anterior and posterior tibial arteries were again found to be thrombosed. AngioJet thrombectomy and EkoSonic (EKOS Corporation) catheter-mediated lytic therapies, followed by removal of the catheter and PTA, were performed (Figure 3A-D).

Post Revascularization Care 

Local wound care was consulted for assistance with the non-healing left TMA with bony exposure. Transcutaneous oxygenation measurement (TCOM) demonstrated poor flow to the lateral aspect of the left TMA. An oxygen challenge was performed and results indicated significant improvement of tissue oxygenation leading to the initiation of daily HBO. In addition to the initiation of HBO, the patient also underwent debridement and revision of the TMA with wound vacuum placement. Due to evidence of osteomyelitis (OM) by bone culture, 6 weeks of intravenous antibiotics were initiated by Infectious Disease (ID) and the patient was ultimately discharged with a peripherally inserted central catheter (PICC) line for home infusion.

The patient remained hospitalized for two weeks, under the care of her multi-disciplinary team, which included interventional cardiology, podiatry, wound care, infectious disease, physical therapy, diabetes education and pharmacy. HBO continues daily and she is being vigilantly assessed, including frequent wound and Doppler examinations, per the authors’ institutional peripheral vascular interventional follow-up protocol. 

Disclosure: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via J.A. Mustapha, MD, at jihad.mustapha@metrogr.org