Endovascular Management of Critical Limb Ischemia ARCH 2020

Endovascular Management of Critical Limb Ischemia ARCH 2020 November 19, 2020 Mount Sinai Hospital New York, N. Y.

HPI 77 y. o. woman with a h/o PAD presenting with severe bilateral leg pain and cramps at rest, worse on the right side with associated non-healing right foot ulcer involving hallux and toes. (Rutherford class III, category 5, Fontaine IV). Reports increased erythema and pain of 4 th-5 th toes of late and over the anterior shin. Denied fever/chills. Intact sensation and motor function of the foot; limited by pain PMH: Atrial fibrillation (on coumadin), May-Thurner syndrome s/p L EIV stent in 09/23/20, CAD s/p PCI, former smoker, COPD, PAD s/p atherectomy/PTA of bilateral ATA/PTA (most recently 07/2019), hypothyroidism, hypertension, diabetes mellitus with neuropathy Medications: Atenolol, Plavix, Coumadin, Insulin, levothyroxine, Pantoprazole, Albuterol, Atorvastatin, Torsemide, Metformin

Presentation Exam: Vitals: 170/83, HR 68, RR 14, sats 94% RA, Temp 98. 6 General: Alert, oriented x 3, no acute distress Head: EOMI, anicteric Neck: supple, no masses ABD: soft, NT, ND, + bowel sounds Neuro: gait normal, motor grossly intact Lower Extremity: nonpalpable pedal pulses on right. Ischemic appearing right hallux ulcer with dry gangrene at the tip, 4 th and 5 th digits with erythema and swelling, tender to palpation Monophasic DP/PT pulses on Doppler Labs: WBC 6. 0, H/H 9. 9/32. 9, plt 218, BUN/Creat 17/1. 03, Hb. A 1 C 8. 0%, CRP 4. 7 Foot X-Ray: Soft tissue edema and ulceration over the first three digits. Cortical margins preserved; no radiographic evidence of osteomyelitis

Non-invasive Testing ABIs 0. 57 on the right, 0. 71 on the left Arterial Duplex Occluded Right mid PT and distal ATA Occluded Left ATA, calcified diffusely diseased peroneal artery

WIf. I Classification Conte MS, Bradbury AW, Kolh P, et. al, Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg. 2019 Jul; 58(1 S): S 1 -S 109. e 33.

Iliac Angiogram via radial access

LLE Angiogram

RLE Angiogram

RLE Below the knee angiogram

RLE Foot Angiogram

ACC/AHA Guideline Recommendation For Treatment of PAD Mehdi H. Shishehbor. Circulation: Cardiovascular Interventions. Volume: 7, Issue: 5, Pages: 642 -644