Critical limb ischemia (CLI) is the end-stage progression of peripheral arterial disease (PAD). Clinical presentation of CLI includes ischemic rest pain, ulceration, or gangrenous loss of tissue due to severely compromised blood flow to the extremity.1-4 CLI complicates wound healing as a result of chronically diminished blood flow that occurs over the course of months to years, and it leads to limb loss secondary to inadequate oxygenated blood flow to the affected limb if left untreated.5
Patients with CLI have several options for management of their severe disease state. Invasive options exist that include endovascular treatment or open surgery to bypass diseased segments and restore blood flow to the affected limb. Best treatment strategy guidelines for patients with CLI have not been established for this population and remain the focus of national clinical trials such as the BASIL and BEST-CLI trials.1,6-8 Advocates for endovascular treatment cite the less invasive revascularization options as having lower complication rates and reduced hospitalization lengths and associated costs, while open surgical bypass generally offers longer viability and a more durable option for revascularization.4,7 National trends demonstrate a recent shift towards using percutaneous methods in the treatment of PAD, which parallels a decrease in open revascularization procedures for PAD and subsequent rates of major amputations.9 Regardless of revascularization method, outcome goals for patients with CLI remain the same: relieve ischemic pain, heal ischemic ulcers, prevent limb loss, improve patient function and quality of life, and prolong survival.1
Patients who undergo medical management for CLI because of nonviable revascularization options resulting from procedural risk from comorbidities and anatomical impedance to arterial access have significantly worse prognoses than patients who can tolerate revascularization attempts.10 Patients with CLI left untreated have survival and limb salvage rates of 46% and 54% after 1 year, respectively.11,12 Limb amputation should be considered as a last treatment option for those with unreconstructable CLI, as amputation significantly limits functional independence and requires a prosthesis to ambulate.8,13 Patients who have undergone limb amputation and continue to present with CLI specifically pose a confounding treatment algorithm.
The present case describes a bilateral above-knee amputee who presented with ischemic rest pain (Rutherford 4). This case highlights an exotic access technique through the left brachial and left profunda femoris arteries to recanalize the occluded iliac and femoral arteries.
A 59-year-old woman presented with a history of bilateral above-knee amputations, prior right-sided common iliac, external iliac, and common femoral arterial stenting, coronary artery disease with coronary arterial stenting, chronic obstructive pulmonary disease, hypertension, hyperlipidemia, diabetes mellitus (Type II), and tobacco dependence. The patient’s bilateral ischemic rest pain was not well controlled on oxycodone, gabapentin, and cilostazol. The ischemic rest pain, even with opioid therapy, prevented the patient from wearing her prostheses. Prior failed attempts to gain access to the bilateral occluded common femoral arteries left the patient with no obvious options for revascularization. After review of previous imaging, left brachial access was deemed most appropriate for a revascularization attempt. An Omni Flush catheter (AngioDynamics) was positioned at the level of the distal aorta for an abdominal aortography with runoff (Figures 1 and 2).
The angiogram demonstrated total occlusion of the right common iliac, external iliac, and common femoral stents. The right superficial artery had a flush ostial occlusion with no appreciable flow. Collateral flow filled in the right profunda femoris, which then provided collaterals to the stump. The left common iliac had appreciable flow, but flow became severely diminished at the start of the left external iliac artery. The left internal iliac fed the left profunda femoris through collateral flow. The left common femoral and left superficial femoral arteries were occluded, mirroring the right lower extremity.
From brachial access, the right occluded common iliac was crossed with a .035-inch Rosen guidewire (Cook Medical) through a NaviCross support catheter (Terumo). The right common iliac was prepared with a 4 mm x 80 mm Armada PTA balloon (Abbott Vascular) at 12 atmospheres. The .035-inch Rosen guidewire was exchanged for a Victory 14 guidewire (Boston Scientific) through a NaviCross support catheter and traversed across the occluded right iliac and common femoral arteries into the profunda femoris. Again, the vessels were prepared with a 5 mm x 200 mm Armada PTA balloon, resulting in approximately 50% residual stenosis due to arterial recoil. A 6 mm x 100 mm Absolute Pro Vascular self-expanding stent (Abbott Vascular) was then placed from the proximal profunda femoris across the right common femoral to the distal external iliac artery. A 6 mm x 100 mm Viabahn covered stent (Gore Medical) was then placed in the distal right external iliac back to the right common iliac, taking the chronic total occlusion (CTO) to 10% residual stenosis (Figure 3). This intervention provided direct inline flow into the right profunda femoris, which went on to provide collateral flow to the right lower extremity stump (Figure 4).
Next, we focused on the left common femoral artery. A Victory 14 guidewire was used to cross the left common femoral artery; however, the wire kept entering the subintimal plane. A dual arterial access approach was adapted to cross the CTO of the left common femoral artery. Retrograde access was achieved in the left profunda femoris, placing a short 4F Micropuncture pedal sheath (Cook Medical) into the left profunda femoris. A .014-inch Astato XS 40 (Asahi Intecc) was advanced through a CXI support catheter (Cook Medical) from the retrograde sheath. The .014-inch Astato XS 40 extended proximally. However, the wire continued to cross the subintimal plane. A 3 mm x 80 mm Advanced Micro balloon (Cook Medical) was advanced from the retrograde sheath and was approximated with a 5 mm x 200 mm Armada PTA balloon from the antegrade sheath. A double balloon angioplasty technique was performed such that the antegrade lumen became fenestrated with the retrograde lumen. This allowed the V-18 ControlWire guidewire (Boston Scientific) to be externalized from left brachial access through the 4F Micropuncture pedal sheath. The 5 mm x 200 mm Armada PTA balloon was advanced across the left common femoral into the profunda femoris. A balloon angioplasty was performed that adequately prepared the arterial vasculature for an Innova self-expanding stent (Boston Scientific) in the left common femoral artery and a Zilver 518 vascular self-expanding stent (Cook Medical) in the left external iliac artery, taking the heavily diseased segments to 10% residual stenosis (Figure 3).
This intervention provided direct inline flow to the left profunda femoris, which then provided collateral flow to the left lower extremity stump (Figure 4).
This patient is atypical in the sense that she has bilateral above-the-knee amputations and presented with ischemic rest pain. However, she should receive the same invasive medical revascularization options offered to ambulating patients with ischemic rest pain. The success of percutaneous methods often depends on the operator’s ability to cross these complex lesions. Exotic accesses that combine anterograde and retrograde approaches show promise in efforts to revascularize complex lesions in patients with CLI.14 In light of significant rates of morbidity and mortality, as well as the large economic burden on the healthcare system, revascularization attempts using exotic accesses should be considered before resorting to medical management of CLI.1,15-17
This case involved a patient deemed to have unreconstructable CLI that resulted in early determination of medical management for CLI before the revascularization described above was performed. The circumstances of this case highlight the need for a consensus among healthcare providers to clearly outline guidelines for treatment of CLI and agree upon a definition of a non-salvageable limb for which amputation is the appropriate course of treatment. Efforts to reduce the usage of opioids, as with the present case that offered revascularization through exotic accesses, should also weigh into the medical treatment algorithm for patients with CLI.
Procedural success in the present case — defined by stenosis reduction and distal reperfusion of bilateral stumps — was dependent upon gaining arterial access through exotic techniques and crossing the CTOs. The occluded common femoral arteries prevented successful retrograde or antegrade attempts for arterial access, and the occluded SFAs made direct SFA arterial access not feasible. An exotic brachial-profunda approach was needed to achieve access to the diseased segments. As a result of the successful PTA and stenting procedures, the patient no longer presents with ischemic rest pain and has significantly reduced reliance on opioids to control pain.
1Duke University of Durham, North Carolina; 2Rex Hospital in Raleigh, North Carolina; 3North Carolina State University of Raleigh, North Carolina
Disclosure: Gabriel T. Brandner, BS, Rachel C. Hurst, BS, and Mason Nagel, BS, have no disclosures. George L. Adams, MD, MHS, FACC, is a trainer and consultant for Cook Medical, as well as a consultant for Abbott Vascular.
George L. Adams, MD, MHS, FACC, can be contacted at email@example.com.
Reprinted with permission from Vascular Disease Management June 2019; 16(6): E82-E84. Copyright 2019 HMP Global.
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