Transcript Left Leg PAD

Kush Agrawal, MD*
With special thanks for contributions to:
Thomas N. Carruthers, MD¶
Jeffrey Kalish, MD¶
Robert T. Eberhardt, MD*
Boston Medical Center
¶Department of Vascular and
Endovascular Surgery
*Department of Medicine, Division
of Cardiology and Vascular Medicine
• Left Leg PAD:
• External Iliac Artery
stent 2001
• Severe Claudication
2010: 40% common
iliac stenosis, occluded
distal SFA and belowknee
popliteal/trifurcation,
2-vessel runoff.
• Intolerant of Pletal
• Rest Pain 7/2013: CFA
endarterectomy and
patchy angioplasty.
Inflow felt adequate, no
CIA intervention.
• Minor trauma 10/2013
to 2nd toegangrene.
Other Past Medical/Surgical
History:
Medications:
1. Hypertension (25+ years)
2. Former Smoker (quit 1990, 45
Pack-Year history)
3. Non-insulin dependent diabetes
mellitus
4. Bilateral 50-60% carotid stenosis.
5. Right Leg PAD: Fem-Pop bypass
2001, complicated by subacute
thrombus in summer 2012,
treated with popliteal and AT
stenting.
Amlodipine 10mg
Isosorbide Mononitrate 120mg
qhs
Aspirin 81 mg
HCTZ 25mg
Lisinopril 40mg
Clopidogrel 75mg
Metoprolol Succinate 50mg
Atorvastatin 40mg
Nitroglycerin 0.4mg SL prn
Metformin 1000mg bid
Amoxicillin/Clavalunate 500 bid
x7d
• 1990: 3vCABG: LIMA to LAD, SVG-RCA, jump SVG-Diag-OM (upper
pole) –OM (lower pole)
• 2007: Unstable Angina (UA): 60% Left Subclavian stenosis, patent LIMA,
occluded SVG-RCA.
• 2009: NSTEMI: BMS to Left Subclavian (SC), DES to lower pole OM graft
(1st layer of stent scaffolding)
• 2011: UA: DES x2 (overlapping) to SVG-OM (2nd layer)
• 2/2012: UA: Native Cors: 95% Left Main, 70% prox LAD, 100% prox LCx,
100% prox RCA. POBA to in-stent restenosis (ISR) of SC stent (40mmHg
gradient); BMS upper pole SVG-OM.
• 4/2012: UA, Rest Angina: Repeat POBA to SC stent and repeat DES to
SVG-OM (3rd layer)
• 8/2012: NSTEMI, Rest Angina: Brachytherapy for SVG-OM: 95% ISR,
50% recoil post-treatment, used cutting balloon that caused edge
thrombus. Passage of Spider distal filter caused thrombus embolization
to retrograde limb of LCx (asymptomatic). Recoiled stented segment of
SVG-OM treated with 4.5 x 38mm Ultra BMS, post-dilated to 5.0 mm
(4th layer!).
• From 2012 to present: suffering from progressive stable angina, CCS II
to III at present, most prominently angina decubitus. Had
gastrointestinal upset with ranolazine and was maximized on isosorbide
mononitrate with stable symptoms, but tenuous cardiac status with
little reserve.
Left Brachial Access
6F Sheath, Monitored
Anesthesia Care
40mmHg gradient at
Left SC artery.
7 x 20mm NC balloon,
high pressure inflation
10mmHg residual
gradient
Left Ileofemoral (s/p Patch Angioplasty)
Iliac Angiogram
85% ostial LCIA lesion. 80mmHg
translesional gradient.
60% LCFA stenosis at site of patch
angioplasty.
mid-SFA, mid-profunda occlusion
w/ reconstitution above knee
Collateral flow below knee
reconstitutes mid-calf
AT to DP runoff to foot;
Diminished PT/Peroneal
★ At this point, we encountered a critical Juncture. He was too high risk for an open
surgical repair, the procedure of choice. Furthermore, autologous veins for
bypass were unavailable, as they were used in prior CABG and R leg bypass.
★The endovascular approach
1) afforded no plaque reduction options (atherectomy) owing to location and
risk,
2) would require bilateral covered iCAST stent in a “kissing” fashion at the aortic
bifurcation,
3) and necessitated upsizing the brachial sheath to a 7F, which would mandate
brachial surgical cutdown for sheath removal.
★Given his aforementioned tenuous cardiac status, the case was halted, a
multidisciplinary conference was held between the patient’s Cardiologist (R.T.E),
Endovascular Surgeon (J.K.) and the patient, and ultimately the endovascular
approach
was chosen, because we had reasonable confidence in success with
the ultimate
outcome being relief of rest pain and improved inflow to the
Step 2. Measurements w sizing catheter
Step 1. Right Iliac System Accessed
Step 3. Up-size to 7F, 90cm
sheath from L Brachial
Step 4. Deploy iCAST balloon-expandable “kissing” covered
stents (left) w/ reconstruction of aortic bifurcation (right)
6mm x 40mm high-pressure inflation
Then 8mm x 40mm low-pressure inflation.
Residual stenosis that was not flow-limiting.
Palpable left DP
Pulse
Resolution of rest
Pain.
Improved healing
and confinement
of gangrene
Stable angina.
• Multi-territory Revascularization requires a multidisciplinary “team” approach to patient care,
balancing interdependence of, in this case, of thoracic, coronary, and peripheral ischemia.
• A thoughtful assessment of the merits and risks of operative vs. endovascular
revascularization is paramount, and the constraints of the anatomic guidelines in TASC I and II
can underserve patients’ needs. TASC III will aid in making more circumspect decisions.
• Creativity (eg. recognizing need for subclavian angioplasty a priori in this case), the ability to”
stop-and-go” during the procedure, and communicating honest expectations (best
confidence in a particular outcome) early on ensure the best possible outcome in very
complicated cases such as this one.
Kush Agrawal, MD*
With special thanks to:
Thomas N. Carruthers, MD¶
Jeffrey Kalish, MD¶
Robert T. Eberhardt, MD*
¶Department of Vascular and
Endovascular Surgery
*Department of Medicine,
Division of Cardiology and
Vascular Medicine