Dr. Charles Dotter performed the first-ever percutaneous transluminal angioplasty in 1964.1 Since the first transluminal angioplasty, the numbers of interventional procedures performed have exploded worldwide. Initial percutaneous vascular interventions (PVI) were confined to the domains of radiology. 2 Yet the last decade has undergone a paradigm shift in the type of specialty and operators who perform PVI. 3 In 2005, the majority of PVI work was performed by cardiologists, 4 followed by radiologists and vascular surgeons. As a cardiologist tiptoes into the vascular territory, turf wars are common. A win-win situation is achieved when the players in the vascular field work together in a multi-disciplinary approach to complex vascular cases. We describe a complex case of critical limb ischemia, approached as a team. Successful results were obtained.
Case Report: Critical Limb Ischemia
A 50-year-old female with past medical history of hypertension, diabetes mellitus, transient ischemic attack, hypercholesterolemia and morbid obesity was seen in the clinic. She presented with right second toe osteomyelitits following nail clipping. She had no wound healing for three months despite continuous antibiotic therapy and maximal medical treatment. Critical limb ischemia, Rutherford category V with a right ankle brachial index (ABI) of 0.63 was documented. Physical examination of the right lower extremity demonstrated a palpable femoral pulse with no palpable popliteal, posterior tibial and dorsalis pedis arterial pulses.
A baseline lower extremity angiogram was performed. This demonstrated the bilateral common iliac artery, external iliac artery and common femoral arteries to have only mild luminal irregularities without any hemodynamically significant stenosis. The right lower extremity runoff showed a Transatlantic Inter-Society Consensus (TASC) D, distal superficial femoral artery (SFA) occlusion. Reconstitution of the proximal popliteal artery via collaterals and one vessel run off via the anterior tibial artery to dorsalis pedis artery was noted. A contralateral approach (cross over technique) from the left common femoral artery was not successful because the lesion could not be crossed successfully into the distal popliteal artery.
The case was presented at the weekly multi-disciplinary vascular conference and an antegrade approach with a femoral artery cut down was discussed. A femoral-popliteal (fem-pop) bypass was not considered as the initial option due the co-morbidities of morbid obesity, hypertension and diabetes mellitus. An ipsilateral antegrade approach is common for such a procedure. However, in a morbidly obese patient, the antegrade approach carries a high risk for vascular access complications of hemorrhage, hematoma, pseudoaneurysm, and/or infection. The popliteal approach to access under ultrasound guidance is also an excellent acceptable option. Once again, placing a morbidly obese patient in the prone position can be cumbersome for the patient and in this case, access to the popliteal artery would result in a very short working length from the puncture site. The dorsalis pedis can be accessed percutaneously; however, it limits the size of the sheath that can be placed and also risks vessel dissection or hematoma that can have deleterious sequelae.
After discussion of all options, a vascular cut down and access of the dorsalis pedis artery was planned. The procedure was performed in the cardiac catheterization laboratory utilizing local anesthesia and conscious sedation. The dorsal aspect of the right foot was prepared and draped in a sterile fashion. The dorsalis pedis artery was identified using a sterile continuous wave 10MHz Doppler probe. A small cut down incision was performed by a vascular surgeon for direct visualization to micro puncture the artery. The vascular surgeon also assisted during the angioplasty of the superficial femoral artery.
A 5 French 10-cm length flexor sheath was introduced over a wire. A 4 French glide catheter (Terumo Medical Corp., Somerset, NJ) and 0.035-inch stiff angled Terumo straight wires were used to cross the occluded distal SFA. The wire was changed to a 0.035-inch angle soft Terumo wire to successfully cannulate the distal SFA into the mid SFA. The recannulation was confirmed by catheter injection and the 0.035-inch wire was exchanged for a 0.018-inch V18 control wire (Boston Scientific, Natick, MA).
Initial balloon angioplasty was performed with 4 x 100 mm Savvy balloon (Cordis Corp., Miami Lakes, FL) followed by 5 x 100 mm Sterling balloon (Boston Scientific). Final angiogram showed a patent distal SFA with Discussion
Complex vascular cases are unique and need a multi-disciplinary approach for the best outcomes. Such combined efforts lead to reduced morbidity, mortality, better patient outcomes, excellent multi-specialty collegial work and a high success rate. At our center, the weekly combined vascular conference gives us the venue to discuss complex cases. Physicians with both surgical and cardiology background provide a planning and strategy to approach complex vascular cases. Such an approach reduces the animosity, turf wars and keeps transparency in patient care. A complex case presented at the conference will have the input from experienced surgeons and the chance to discuss some of the literature. New research ideas are born and nurtured at these conferences. This multi-disciplinary approach is of tremendous learning venue to the participating physicians, residents, students and cardiology fellows.
The operating room assistants bring all the required equipment to the catheterization laboratory and assist the surgeon for such procedures. The cath lab has a state-of-the-art Philips flat-screen 20-inch image intensifier that provides adequate visualization of the arterial vasculature anywhere in the body. The laboratory is routinely used for both coronary and peripheral procedures. The vascular surgeons and the cardiologists have open access to the cath lab use. The cath lab consists of dedicated nurses and technologists who have a passion for peripheral procedures. The technologists, nurses and the lab personnel play a big role in the success of these procedures. Complex cases can take 4 hours and various catheters and equipment are needed routinely. Extra patience and support from the staff at our center has played a pivotal role in our success.
We have had the fortune of working on complex cases in close relationships with the vascular surgeons and other cardiologists, including Dr. Steven Powell (Chief of Vascular Surgery at East Carolina University). Dr. Powell was the vascular surgeon in the case described above and has also worked with us on complex iliac interventions and carotid interventions. Dr. Michael Stoner (Assistant Professor of Vascular Surgery at East Carolina University) has assisted us numerous times in complex PVI utilizing the popliteal access site for SFA interventions and abdominal aortic aneurysm stent grafting. As the number of vascular procedures increases, the need for a multi-disciplinary approach to these complex vascular lesions is an important strategy for optimizing patient care options.
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1. Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction. Description of a new technic and a preliminary report of its application. Circulation 1964;30:654-670.
2. Levin DC, Parker. L, Eschelman DJ, et al. Do interventional radiologists pose a significant threat to the practice of vascular surgery? J Vasc Interv Radiology: 1999 Sep;10(8): 1007-1011.
3. Levin DC, Rao VM, Parker L, et al. Turf wars in radiology: the battle for peripheral vascular interventions. J Am Coll Radiology 2005 Jan;2(1):39-42.
4. CxVascular. Turf wars intensify over endovascular training. Available at: http://www.cxvascular.com/News/News.cfm?ccs=276&cs=1804. Accessed October 16, 2007.