Duration: 9:18 minutes
In this case study, Dr. Dua describes a treatment plan for a 67-year-old male with critical limb ischemia. Presenting with toe gangrene. Patient has a history of peripheral arterial disease with prior right iliofemoral endarterectomy and left femoropopliteal bypass. Diagnostic studies and procedural interventions are detailed.
Welcome to the program. The speaker is a vascular surgeon. Doctor Dua. Doctor Dua is an associate professor of surgery co-director P ad Center, Director of Clinical Research Director of vascular Lab, and associate director of the wound care Center at the Massachusetts General Hospital and Harvard Medical School. It is my pleasure to turn the program over to Doctor Dua. Thank you so much for having me. I'm thrilled to be here today. So before we get started, let's get the disclaimer out of the way. Um I have nothing really to disclose on my end, but just wanna leave this up here for uh the rest of you to just take a look at. Now we're patients that we used to just say, hey, they've got P ad, let's get them to walk and let's get them to change their habits, that's not working anymore for a lot of patients. So, what I wanna do today is I want to give you an example of a patient that really brings together a number of concepts that we have clinically that go through our head when faced with a patient. And you have to take into account how sick the patient is what you're going to have to do for them in the future. Potentially, this is AAA man who presented with a left second to a wet gangrene and he did have a history of peripheral artery disease and a history on the right side of an iliofemoral endarectomy in a left fem pop bypass. But he was presenting with left toe gangrene and presenting in the middle of the night, no less. He had all the past medical history that you would expect of this type of patient hypertension hyperlipidemia. Of course, a reduced ejection fraction. Very important from an anesthetic standpoint. He did have coronary artery disease and he'd previously had a coronary artery bypass. He was of course type two diabetic. He was a former smoker and he had quit 20 years ago. So it was a very positive thing going for him and he was on uh Apixaban aspirin and atorvastatin when he presented his white count was 15 and this is what his toe looked like. Wet gangrene at the bedside. He had that high white count and he had a toe wound initially. When looking at this patient, I had to deal with was the clinical important thing at that moment. And what was that, that white to of 15. And the fact that he had presented in the middle of the night with pain and wet gangrene that meant that there's no salvaging that toe, that toe needed to go and that meant now I was sitting on, on a patient where I had no clinical data as to what their perfusion was in that leg. But I did know that he currently sick from what was going on. So what I did was I took him to the operating room to do that left toe amputation. And because I knew that I was going to be left with an open site, an open wound site, I wanted to know what my perfusion status was. So I did go ahead and do that second toe amputation and did do a uh lower extremity angiogram. My intention was to treat him to get blood flow if I needed to. But when I got in there, what do I see? Calcium everywhere I did go from the opposite side. And I will always do that in a patient that I am. Uh if I can feel femoral pulses and that I um I'm I'm a, I'm approaching without any knowledge of what their iliac system is. And the reason for that is how do I know that he doesn't have a tight lesion in his common iliac? And even if I go and do a beautiful job, Antegrade on the leg, that was the issue. I may have missed an inflow problem, which is an issue for me. So that's why I always from the contralateral side. So sure enough, you can see his aortogram here, you saw that flow. Um And it's not block it, excuse me. But it, it, it is um uh crunchy with a lot of uh plaque. Now, here's a decision point. I get to his common femoral, put my catheter as you can see my cat right here, put my cat here and I do a angiogram. And what I noticed is he has a tight lesion right here between the Profunda and the S fa now I have a decision to make. I know that he's got this tight lesion. Do I try to push my cat through possibly dissecting this area or do I recognize that he probably needs a femoral endarterectomy to really open up that Profunda and that S fa and then I can go integrate maybe and continue my procedure, decision making point. What I did was I continued my angiogram. Did it did continue the rest of the angiogram from above that lesion that I just showed you. What I saw is a lot of collaterals, lot of blockages within the S fa sluggish flow. And then as I'm moving down the leg, I really just see the single A T runoff. So again, I have a decision to make here. Do I go ahead and say this is a patient that's never gonna heal, check him for vein and do a fem a bypass to try to get that flow open? Or do I try to approach this patient with a purely endo procedure and try to get through that lesion that I just saw what I opted to do in this patient because I have the ability to do both is I was able to take him for a left femoral endarterectomy the next day with an integrate stick of the bovine patch. Now, why that? Because I didn't believe my angiogram, that's why I knew that I was shooting guy from above that tight lesion in the common femoral, which meant that even though I only saw single vessel runoff, it's very possible that this patient who's about 60 years old has multiple vessel runoff. And I'm just not seeing it because I'm not getting enough dye down there. So I also knew because this guy had such a crunchy aorta and iliac and had previously had a femoral enterectomy and a bypass on the other side and he was young at 60. But this is somebody that I'm going to see again. So if I can do a left iliofemoral enterectomy and now have a door into this patient's body for the rest of his life to be able to fix whatever he needs in the future. That's a positive thing, right? So that's why I went ahead and did this procedure first. Now, I then did a left lower extremity angiogram. And while I've told you all this already about what I did, there's a reason why I went this route versus doing a uh operative route after I put the um uh catheter into the patient's S FA and I did a uh recanalization of the couple of areas that you saw in the S FA that were tight. I was then able to note that there was grateful going all the way down to the patient's foot. As I said earlier, I had had no diagnostic studies on the patient when I first saw him in the er, so after I did his initial procedure, just the toe amputation and the initial engine I did get these PB RS. And the reason I did that was to see is there any chance that I would be able to get better flow down all the way to the, to the, to the toe? Because I knew that with a toe pressure of zero, what I did then is I went ahead, did an angiogram through my patch, recanalize the S fa as you can see here, you can see this huge collateral, right? And look at that there's actually clearly two of us will run off, maybe three of us will run off when I get my catheter all the way down to the patient's pup and down to the foot, beautiful flow via two vessels. So then what I ended up doing is now that I realize that and I had my catheter all the way down. I decided to go ahead with DC B of this patient's area. Now you might say, well, why not stent? The reason I decided not to is because at this point, I wanted to see what A DC B would do for this particular patient, as you can see here all the way down. Now, we have three vessel runoff. Now, is this gonna last this patient forever? Probably not, but maybe next time I could bypass to his PT or his A T depending on what he needs or maybe now with this new flow that's in line and perfect, he might be able to walk and build up collateral such that he may never need another procedure. These are all options for him. But at this point after doing this and of vascular, I didn't feel like he needed anything further from a surgical perspective. You can see this three vessel runoff now all the way from the top and I'll show you the foot in a second here. So after we finished doing the procedure, good result in my opinion, I put the patient on Aspirin and the 2.5 of R and B I Ds for the Voyager trial. And I ensured that he had toe pressures and ankle brachial disease followed up. And indeed, when I saw him in follow up, his toe pressure was greater than 55. Um This was not about a month after I done my initial procedure. So it does take a little bit of time for some of those vessels to plump up down in the foot and get some great flow. So if you're ever in a situation where you have an option to wait to do a toe amputation, which I did not in this case, but had I, I would have waited at least a couple weeks before doing a toe amputation if I could have waited. But in a patient with a high white count and wet gangrene, you really can't. Of course, I survey these patients very closely with toll pressures because I wanna ensure that whatever I've done for him specifically is S fa that's been recanalized, but I am still following up with him and I'll ensure I'll be seeing this patient. Um uh uh basically throughout his life every six months to make sure that he doesn't develop any further wounds and that he's appropriately being medically managed so that all his cardiovascular risk from heart attack and stroke is also managed in conjunction with his P AD. Thank you so much for your time.
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