Dr Abadir Severe Claudication Amputation Prevention Case

Dr. Abadir received specialty fellowship training at Columbia Presbyterian Hospital. He is board certified by the American Board of Radiology in Diagnostic Radiology, with a certificate of added qualification in Vascular & Interventional Radiology.

Patient History and Consultation

• 80-year-old patient with severe claudication and rest pain of the LLE.  The patient was only able to walk 50 ft before the onset of severe calf cramps and a burning sensation in the foot requiring rest.  Wakes at night with calf and foot pain relieved by dependent positioning.  Long vascular history with prior SMA and celiac stents, iliac stents, and RLE angioplasty
• PMHx:
  CAD s/p MI x3
  HTN
  PVD
  DM
  Hypothyroid
  Obesity
  Prior smoker
• Medications:
  Plavix
  Rosuvastatin
  Zetia
  Levothyroxine
  Metformin
  Maxzide
• Physical Exam.  The left foot is cool to the touch.  Normal femoral pulse. No popliteal or distal pulses. Mild rubor with no ulceration

Physical Non-Invasive Evaluation

• Preliminary Evaluation
• PVR with a severe reduction in left ABI and marked loss of pulsatility below the knee

Treatment Plan

• Patient maximized medically
• Poor candidate for surgery due to comorbidities
• Proceed with endovascular intervention with possible atherectomy/angioplasty and stent

Procedure

Occlusion of left SFA and Popliteal artery with reconstitution of isolated tibial vessels.  Poor collateralization noted

Distal Anterior Tibial and Peroneal arteries are patents, but diseased

Subintimal angioplasty through SFA to Peroneal with SFA and Popliteal stents

Subintimal angioplasty extended into Anterior Tibial artery with angioplasty of distal Peroneal artery and Anterior Tibial Artery

Patient Follow-Up

• Complete resolution of LLE claudication and rest pain
• Normalized PVR in the left leg

Discussion

• Percutaneous revascularization of the leg with long segment occlusions and poor target vessels in a patient who is a poor surgical candidate.
• Patient to continue with Statins and dual antiplatelet therapy.
• Complex endovascular interventions are now feasible for distal vessel disease.  Emerging technologies such as catheter-based optical coherent imaging to visualize the former lumen of vessels will continue to extend the ability to recanalize long segment occlusions.