CLI Case Study Jihad A. Mustapha, MD, FACC, FSCAI Advanced Cardiac & Vascular Centers for Amputation Prevention Grand Rapids, MI, USA Clinical Associate Professor of Medicine Michigan State University College of Human Medicine E. Lansing, MI, USA
Disclosures • BD Bard: Consultant • Boston Scientific: Consultant and Research • CardioFlow: Equity Ownership and Board Member • Cardiovascular Systems, Inc: Consultant • Medtronic: Consultant • Micromedical: Chief Medical Officer • Philips: Consultant • PQ Bypass: Consultant and Research • Terumo: Consultant Brand names are included in this presentation for participant clarification purposes only. No product promotion should be inferred.
CLI Case Study • 57 year old male • History of Type 2 DM, COPD, CAD, HTN, HLD, Obesity & Smoking • Referred by operator who was unable to obtain antegrade access to revascularize AT and pedal loop • Presented with non-healing TMA of left foot with dehisced wound, infection at anastomosis of the plantar and dorsal skin with gangrenous changes (Rutherford Class 6)
Complex Case Presentation • Body habitus • Multiple comorbidities • Previous failed procedures • Rutherford Class 6 • Limb salvage case
Reversing Retrograde Access to Antegrade in Challenging Body Habitus Retro image with oblique view showing Retrograde angiogram with Mini Omni the retro sheath arteriotomy above the Flush in place SFA/Peroneal bifurcation
Sheath tip is reversed from Using the profunda to anchor the retrograde to antegrade support wire
Selective antegrade angiogram Dessert foot
Pedal loop engaging the Anomalous take-off of the AT and peroneal, AT, DP and lateral plantar arteries DP from the peroneal artery
Pre PTA IVUS Peroneal/AT Junction
IVUS directed PTA with 5.0 mm IVUS demonstrating eccentric balloon plaque
Where does the disease start and where does it end? Left DP post balloon recoil
Anomalous AT take-off demonstrating peroneal artery is still 100% occluded
4.0 mm balloon at 4 ATMs in the 3.5 mm balloon peroneal/AT junction
4.0 mm balloon at 6 ATMs in the 4.0 mm balloon in the DP as peroneal/AT junction shown by EVUS (1.1:1.0 ratio)
Post revascularization angiogram Post revascularization angiogram of the peroneal, AT and DP of the AT, DP and plantars
Demonstration via angiography of intact complete pedal loop Demonstration via angiography of complete ped
1.1:1.0 balloon ratio (utilizing 6.0 mm balloon) in the TPT and proximal peroneal arteries with excellent results
2 Week Post Revascularization Follow up • Patient presented with progression of healing of left TMA site. • Foot warm, brisk capillary refill • Biphasic PT and DP pulses by Doppler • Patient has stopped smoking and remains on optimal medical therapy with DAPT • Continues to follow with podiatry and wound clinic • Will return in 2 weeks for arterial DUS
Conclusions • With proper imaging modalities such as IVUS, we no longer fear proper balloon sizing or fear using 6.0mm balloons when indicated in the tibial arteries. • Use and apply IVUS and EVUS data to obtain safe and effective results for best patient outcomes.
Jihad A. Mustapha, MD, FACC, FSCAI jmustapha@acvcenters.com @mustapja THANK YOU
Recommend
More recommend
