SLIDE 1 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
SLIDE 2 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.
SLIDE 3 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)
SLIDE 4 Complex Case Presentation
- Body habitus
- Multiple comorbidities
- Previous failed procedures
- Rutherford Class 6
- Limb salvage case
SLIDE 5
Reversing Retrograde Access to Antegrade in Challenging Body Habitus
Retrograde angiogram with Mini Omni Flush in place Retro image with oblique view showing the retro sheath arteriotomy above the SFA/Peroneal bifurcation
SLIDE 6
Sheath tip is reversed from retrograde to antegrade Using the profunda to anchor the support wire
SLIDE 7
Selective antegrade angiogram Dessert foot
SLIDE 8
Anomalous take-off of the AT and DP from the peroneal artery Pedal loop engaging the peroneal, AT, DP and lateral plantar arteries
SLIDE 9
Pre PTA IVUS Peroneal/AT Junction
SLIDE 10
IVUS directed PTA with 5.0 mm balloon IVUS demonstrating eccentric plaque
SLIDE 11
Where does the disease start and where does it end? Left DP post balloon recoil
SLIDE 12
Anomalous AT take-off demonstrating peroneal artery is still 100% occluded
SLIDE 13
3.5 mm balloon 4.0 mm balloon at 4 ATMs in the peroneal/AT junction
SLIDE 14
4.0 mm balloon at 6 ATMs in the peroneal/AT junction 4.0 mm balloon in the DP as shown by EVUS (1.1:1.0 ratio)
SLIDE 15 Post revascularization angiogram
- f the peroneal, AT and DP
Post revascularization angiogram
- f the AT, DP and plantars
SLIDE 16 Demonstration via angiography of intact complete pedal loop
Demonstration via angiography of complete ped
SLIDE 17
1.1:1.0 balloon ratio (utilizing 6.0 mm balloon) in the TPT and proximal peroneal arteries with excellent results
SLIDE 18 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
SLIDE 19 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.
SLIDE 20
THANK YOU
Jihad A. Mustapha, MD, FACC, FSCAI jmustapha@acvcenters.com @mustapja
