Limb Salvage Endovascular Technique in Chronic Limb-Threatening Ischemia

A 63-year-old female with PAD (Fontaine III, Rutherford 4), coronary artery disease, hypertension, hyperlipidemia, stroke without residual neurologic deficits, and a 60-pack year smoking history presented with progressively worsening right foot severe rest pain for a week. She had a pertinent history of peripheral vascular intervention for acute right-limb ischemia treated with catheter-directed thrombolysis and subsequent stenting of the superficial femoral artery (SFA) with two 6- x 60-mm Smart stents (Cordis), 4- x 60-mm Xpert stent (Abbott) extending from the distal P3 popliteal artery (POP) into the proximal anterior tibial artery (ATA), and a 3- x 40-mm Xpert stent in the mid ATA 9 years prior to the index presentation. At this admission, she had a left transfemoral distal aortogram with selective right-leg angiography, which revealed 75% stenosis in the right common iliac artery (CIA) and in-stent chronic total occlusion (CTO) of the right SFA extending through the entire popliteal artery with severe infrapopliteal disease. She had a single-vessel runoff on the right with a chronically occluded ATA filling from geniculate collaterals without good visualization of inframalleolar vessels due to motion artifact because of severe pain. The tibioperoneal trunk (TPT), proximal peroneal artery (PRA), and entire posterior tibial artery (PTA) were chronically occluded with a faintly filling lateral plantar artery. Initially, an endovascular approach was chosen for revascularization. The right SFA in-stent CTO was not crossed with antegrade 4-Fr Glide catheter (Terumo) and .035˝ Glide wire (Cordis) manipulation.

After discussion of the treatment options and with a goal of limb salvage, she was evaluated for bypass surgery even though the outflow target vessel was not ideal as the distal bed was not well visualized. She underwent right common femoral artery (CFA) to ATA bypass with a nonreversed saphenous vein harvested from the left leg (Figure 1). Arterial Doppler the next day revealed occlusion of the bypass due to poor outflow. Without a residual autologous conduit, she was no longer an ideal surgical candidate and was discharged with follow-up in the wound care clinic. Her tissue oximetry was 3 mm Hg on the dorsum and 23 mm Hg on the medial aspect of the foot, below the healing threshold.

One month after her admission, she developed a right great toe ulcer with early ischemic changes in the 4th toe, which was now Fontaine IV, Rutherford 5 (Figure 2). Her care team referred her to our center for revascularization. In an attempt to salvage her limb, she underwent another angiogram with general anesthesia to eliminate any motion artifact due to pain. The study revealed 75% right common iliac artery (CIA) disease, proximal SFA in-stent CTO with a concave proximal cap, P1 to P3 segment POP-CTO, mid right ATA in-stent CTO, PTA-CTO, and TPT-CTO with distal reconstitution of PRA from an anterior communicator branch of the ATA. PRA provided collaterals to the distal PTA and dorsalis pedis artery (DPA), forming an intact palmar arch (Figure 3 and Figure 4).

She was re-evaluated for revascularization to prevent a major amputation. The new strategy was based on antegrade and retrograde access with possible subintimal flossing with delivery of therapy from the antegrade access. The retrograde access was obtained to assist with crossing of the extensive multilevel disease. Extravascular ultrasound (EVUS)-guided left CFA and retrograde right DPA were obtained. A 7-Fr x 45-cm Destination sheath (Terumo) was inserted in the left CFA and a retrograde 2.9-Fr micropuncture pedal sheath (Cook Medical) was inserted in the right DPA. The combination of an angulated, 150-cm, .035˝ Navicross (Terumo) with 0.035” Glidewire Advantage support catheter (Terumo) crossed the proximal SFA-CTO cap intraluminally then crossed subintimally from the mid SFA to the P3 POP artery segment. Through the retrograde 2.9-Fr micropuncture pedal sheath, an .018˝ CXI support catheter (Cook Medical) and an .014˝ Fielder XT wire (Asahi Intecc) were advanced through the DPA into the anterior malleolar collateral into the PRA for rendezvous with the antegrade catheter in the ostial TPT for wire externalization. After removal of the Fielder XT wire, a V18 wire (Boston Scientific) was inserted through the retrograde .018˝ CXI support catheter and advanced in the antegrade .035˝ Navicross catheter (Figure 5 and Figure 6). We ­established subintimal arterial flossing with antegrade-retrograde intervention (SAFARI technique) in the TPT through the struts of the previously deployed stent extending from the distal POP to the proximal ATA with a 330-cm-long, .014˝ ViperWire. An .014˝ Eagle Eye intravascular ultrasound (IVUS) catheter (Philips) was inserted for additional evaluation and to determine the optimal treatment. IVUS revealed moderate circumferential plaque, subintimal SFA and POP crossing, and intraluminal PRA crossing with re-entry in the TPT. An Emboshield NAV6 distal embolic filter (Abbott) was placed in the distal PRA to protect the single vessel to the foot. The PRA was predilated with a 3.5- x 150-mm Ultraverse balloon (BD). The TPT was predilated with a 4.0- x 150-mm Ultraverse balloon. The POP was serially predilated with 4.0- x 150-mm, 5.0- x 150-mm, and 6.0- x 150-mm Ultraverse balloons. The SFA was serially predilated with 5.0- x 150-mm, 6- x 150-mm, and 7- x 150-mm Ultraverse balloons.

Ultimately, stents were deployed from the proximal PRA to the proximal SFA, starting with a 3.5- x 38-mm Resolute (Medtronic) drug-eluting stent, a 4.0- x 38-mm Resolute drug-eluting stent postdilated with a 5.0-mm balloon, a 5.5- x 150-mm Supera stent (Abbott), a 6.0- x 150-mm Supera stent, and a 7- x 140-mm Zilver PTX stent (Cook Medical). Finally, the right CIA was treated with an 8- x 56-mm Valeo balloon-expandable stent (BD Bard) postdilated with a 10-mm balloon (Figure 7 and Figure 8). IVUS revealed well-apposed stents. After removal of the filter, hemostasis of the left CFA was achieved with a ProGlide closure device (Abbott) and manual pressure for the retrograde DPA access.

The patient was discharged on aspirin, clopidogrel, atorvastatin, and losartan. She was referred to a smoking cessation program and wound care. She underwent partial right great toe amputation, which healed after 3 months of aggressive wound care (Figure 9).