Can Endovascular Atherectomy Be Beneficial In Diabetic Limb Salvage?

By Peter Wilusz, DPM, and Guy Pupp, DPM

Case Study: A Patient With Severe Claudication And Ulceration

In one case study, a 69-year-old male was referred to a lower extremity limb salvage clinic with severe painful claudication and ulceration.      He had prior amputation of the hallux and second digit of the right foot secondary to gangrene, and a prior endovascular angioplasty of the anterior tibial artery. He was scheduled for a below-knee amputation at another facility. His past medical history included diabetes mellitus for eight years, hypertensive cardiovascular disease and chronic renal failure, which initially required dialysis and eventually led to a right orthotopic kidney transplant. The patient history also included monocular blindness in the right eye.      The patient was a former smoker who quit 30 years ago. His family history was significant for diabetes mellitus maternally and morbid obesity. He did have night cramps and reproducible leg pain with ambulation. His medications included Medrol, Cellcept, Prograf, Avandia, Zocor, Ambien, Atenolol, aspirin and insulin. He denied any known allergies.      In regard to the physical exam, the patient’s vital signs were stable. His blood pressure was 137/84, his pulse was 80, respirations were 14 and his temperature was 98.5ºF. His pain was seven out of 10 on the visual analogue scale (VAS). His random blood sugar (RBS) at three hours postprandial was 131 mg/dL. The vascular exam revealed non-palpable pulses to the right lower extremity. The title= After delivering the catheter to the lesion, one would position it at the selected treatment area and switch the driver on. Switching the driver on automatically deflects the catheter tip, lifts the cutter and activates the motor. Doppler exam revealed a non-Dopplerable posterior tibial artery and a weakly monophasic dorsalis pedis artery. The distal foot was cool to the touch with elevated capillary refill time. An open ulcer was present at the prior amputation site of the first and second digits with gangrenous changes present. His right ankle-brachial index (ABI) was 0.69. Previous vascular intervention results included a balloon angioplasty of the right anterior tibial artery. His prior angiogram revealed a 100 percent occlusion of the posterior tibial artery and 75 percent stenosis of the proximal anterior tibial and fibular arteries.      We referred the patient to a cardiovascular interventionalist for immediate vascular evaluation. The patient underwent a selective abdominal aortogram, which revealed severe infrapopliteal disease bilaterally. The posterior and anterior tibial arteries are 100 percent occluded proximally. The peroneal artery was patent and supplied collateral arterial circulation to the distal anterior and posterior tibial arteries.      The patient underwent endovascular intervention including laser atherectomy, Silverhawk endovascular atherectomy and balloon angioplasty of the anterior tibial artery. The patient required a transmetatarsal amputation (TMA) after the Silverhawk procedure but avoided the need for a significant proximal amputation. There were no complications while healing the TMA. He exhibited no further complications 12 months after the endoscopic atherectomy.

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