Complex Critical Leg Ischemia

History

The patient is 56-year-old man with a history of diabetes mellitus, peripheral arterial disease, and non-healing ulcer of the left lower extremity who was referred by a doctor of podiatric medicine (DPM) for further evaluation of his peripheral vascular disease. Due to the non-healing ulcer and markedly diminished pulses, we decided to proceed with angiography.

Indication

Left lower extremity ulcer.

Angiographic findings

The abdominal aorta is patent; there is a right ostial iliac lesion of 30%. The left ostial iliac is totally occluded (Figure 1). The left common iliac artery is occluded, and the left external common femoral, superficial femoral and most of the left popliteal arteries are occluded. The tibial vessels were not visible. The right external iliac is patent, right common femoral is patent, the right superficial femoral artery is totally occluded and reconstitutes distally, and the right popliteal is patent with 3-vessel runoff below the knee.  

Due to the findings and ulcer of the left lower extremity, we proceeded with intervention of the left leg.  The patient is not a candidate for bypass due to comorbidties. 

Procedure

The patient was draped in sterile fashion. Using standard Seldinger technique with a micropuncture needle, we placed a 5 French sheath. An abdominal aortogram was obtained and the findings were as indicated above. The patient had an ostial left common iliac lesion that we initially tried to traverse using the universal flush catheter and a stiff Glidewire (Terumo), but the wire would not cross. We then exchanged for a Motarjeme catheter (Merit Medical) and over several attempts, tried to advance the wire through the occlusion. We then decided to upsize the sheath to a 7 French, 45 cm, Balkin modified sheath (Cook Medical) for support and, using the Motarjeme catheter, we advanced a stiff Glidewire into the left common iliac artery. A bivalirudin (Angiomax, The Medicines Company) bolus and drip was started.

Afterwards, we exchanged for a straight, stiff wire and advanced it further into the left common femoral artery. Now at the common femoral, we used ultrasound guidance to advance a stiff Glidewire into the superficial femoral artery. Using the wire loop technique, we traversed the entire segment of the superficial femoral artery and our wire was placed into the left posterior artery. We confirmed our placement with a Quick-Cross catheter (Spectranetics), replaced the Glidewire with a Spartacore .014” 300 cm (Abbott Vascular). We then performed balloon angioplasty throughout the common femoral and superficial femoral artery with a 6 x 100 mm balloon (Figure 2).

Two wire-interwoven nitinol Supera Veritas stents (Idev Technologies) were placed from the popliteal artery back to the mid to proximal superficial femoral artery, followed by a standard nitinol stent (Covidien) (Figures 3-5). These stents were then post dilated. At this point, we performed angioplasty with a scoring balloon at the common femoral and proximal to that, a covered stent was utilized in the external iliac. There was still some residual stenosis at the ostial left common iliac; therefore, a bare-metal balloon-expandable stent (Medtronic) was placed. 

After an angiogram, there was some contrast hang-up in the peroneal and anterior tibial arteries. The patient had severe disease below the knee. An eptifibatide (Integrilin, Millennium Pharmaceuticals) drip was hung. The patient had an 80% stenosis of the posterior tibal artery. We removed our wire from the posterior tibal artery to the anterior tibial artery and performed percutaneous transluminal angioplasty (PTA); we then wired the posterior tibial artery and performed PTA. Significant residual stenosis of the anterior tibial artery was still present. Due to the left lower extremity ulcer, a paclitaxel-eluting 3.0 x 28 mm Ion stent (Boston Scientific) was placed in the anterior tibial artery. At this point, one vessel runoff has been restored (Figure 6).

The left common and external arteries are patent. The left superficial femoral artery and popliteal arteries are patent. The left anterior tibial artery is patent, the left peroneal artery has a 70% proximal occlusion, and the left posterior tibial has an 80% occlusion (Figure 7).

Plan

The patient will be continued on dual antiplatelet therapy and followed up with serial ultrasound at 3 and 6 months. He will be considered for re-intervention of the peroneal and posterior tibial arteries. 

Save a leg, save a life! 

Dr. Nader Chadda and Orlando Marrero can be contacted at orlm8597@yahoo.com.

Disclosure: Orlando Marrero reports he is an employee of IDEV Technologies.