Exploring Limb Salvage Options In Patients With Chronic Limb Ischemia

By John E. Aruny, MD, Peter Blume, DPM, Bauer Sumpio, MD, PhD, and Benjamin Buren, DPM

   The patient had a significant past medical history including PVD, diabetes, coronary artery disease, hypertension, hypercholesterolemia, myocardial infarction, chronic renal insufficiency, peripheral neuropathy and gangrene of the left third toe. She underwent a coronary artery bypass and cholecystectomy on Sept. 7. An attempted lower extremity bypass graft was unsuccessful on Sept. 24.

   Her medications included oxycodone hydrochloride 40 mg bid, atorvastatin calcium 10 mg daily, metoprolol 50 mg bid, amlodipine 5 mg daily, lisinopril 20 mg daily, stool softener 100 mg daily, aspirin 81 mg daily, a daily multivitamin and silver sulfadiazine cream. The patient is allergic to ibuprofen.

   In general, the patient was in no apparent distress and was alert and oriented. She had a regular heart rate and rhythm with positive S1 and S2 heart sounds. Her lungs were clear to auscultation bilaterally with no rhonchi, rales or wheezing. Her abdomen was soft, nontender and nondistended with positive bowel sounds.

   The lower extremity examination revealed a left, dry necrotic third digit with no discharge and no erythema. The patient had been using silver sulfadizaine cream on the dorsal and plantar aspects of the foot. The patient had nonpalpable dorsalis pedis and posterior tibial pulses with weak monophasic Doppler signals. Multiple ischemic lesions on the dorsal and plantar aspect of the forefoot were secondary to recent skin biopsies. The patient also had skin staples to the dorsum of the ankle and lower leg from the recent lower extremity bypass attempt.

What Did The Angiogram Reveal?

   An angiogram revealed extensive tibial peroneal disease on the left limb with occlusion of all vessels to the mid-calf level. There was reconstitution in the anterior tibial that provided dominant flow to the foot and reconstitution of the dorsalis pedis artery. A MRI of the left foot revealed multiple areas of small abscesses associated with the ischemic ulcers but no evidence of osteomyelitis.

   After the failed bypass, vascular surgeons were consulted and repeat vein mapping confirmed the absence of a usable vein conduit. With the history of aborted left lower extremity bypass, the multidisciplinary team planned for endovascular limb salvage with interventional radiology. Noninvasive vascular testing included TcPO2 of the left pretibial region (49 mmHg) and the left dorsum (30 mmHg).

   A diagnostic angiogram prior to the aborted surgical procedure revealed a patent abdominal aorta, iliac arteries and left superficial femoral artery. The femoral bifurcation was intact. The above- and below-the-knee popliteal artery also was patent and without stenosis.

   The posterior tibial artery was occluded at the level of the mid-calf. The peroneal artery was severely diseased. The anterior tibial artery had proximal, hemodynamically significant stenosis and a 30 mm long occluded segment at the level of the lower one-third of the calf. There was hemodynamically significant stenosis of the dorsalis pedis artery at and just below the level of the ankle joint.

A Guide To Understanding The Cryoplasty Procedure

   After completing angiogram procedures, surgeons performed an antegrade puncture of the left common femoral artery and placed a 6-Fr sidearm sheath with its tip in the proximal superficial femoral artery. A repeat diagnostic study confirmed the previous findings.

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