Author + information
- Takumi Inoue1,
- Susumu Odajima2,
- Kentaro Yamashita1,
- Taro Kamada1,
- Shun Yokota1,
- Daisuke Tsuda1,
- Masamichi Iwasaki1,
- Hiroshi Okamoto1 and
- Takatoshi Hayashi1
Patient initials or identifier number
Relevant clinical history and physical exam
A 87 years-old woman suffers from coldness of her each finger every winter. This ambulatory woman had rest pain in her right foot 2 months ago, and referred to our hospital with a deeply erythematous on her right foot. Past medical history included hypertension alone. She did not have any episode of smoking, diabetes, and intermittent claudication. At clinical examination, her right leg was extremely painful and edematous, and intractable skin ulcers emerged on from her 2nd to 4th fingers.
Relevant test results prior to catheterization
A Initial laboratory examination revealed left shift of leucocyte without C-reactive protein (CRP) elevation (Leucocyte 6,700/μl, granulocyte 93.1%, CRP 0.43 mg/dl), normal renal function,positive anti-centro-mere, anti-SSA and anti-SSB antibody test. Based on these antibody test, we made a diagnosis of limited cutaneous systemic sclerosis (lcSSc) with Sjögren's syndrome. Her right ankle/brachial index (ABI) was unmeasurable. Skin perfusion pressure (SPP) of her right plantar was 7 mmHg.
Relevant catheterization findings
Initial angiogram showed around 15 cm occlusion of right superficial femoral artery (SFA), total occlusion of right anterior tibialis (ATA), posterior tibialis (PTA), and peroneal artery (PA), and severe stenosis of tibioperoneal trunk supplied collateral flow to pedal artery, resulted in very little pedal filling. Then we tried endovascular therapy (EVT) to right SFA occlusive disease and to below the knee (BTK).
We used ipsilateral approach. 0.014 inchs Command wire (Abbott Vascular, Illinois) was able to penetrate the SFA occlusive lesion by intravascular ultrasound (IVUS) knuckle technique without bi-directional approach. As a large amount of clot was aspirated, the SFA occlusive lesion was dilated by 5 mm balloon and 6 mm self expandable bare metal stent was implanted under deployment of distal protection device at popliteal artery. After no distal embolism to BTK lesion was affirmed, we tried EVT to BTK lesion consequently. We tried angioplasty in the ATA long occluded lesion, but failed to cross it because of too tiny vessel distal to the lesion at below the ankle (BTA), which converted to anlioplastyin severe stenosis of tibioperoneal trunk. To increase collateral flow to pedal artery, we selected 2 mm balloon to dilate tibioperoneal trunk. Final angiogram shown as Figure 3. As systemic vascular disease related with lcSSc and presence of ischemic pain could make vessel at BTA lesion more narrow, lumbar sympathetic nerve blockade was introduced to the patient. SPPs at her right dorsal and plantar on the day after the indexed EVT were 21 and 14 mmHg, respectively. At 9 days after lumbar sympathetic nerve blockade, her rest pain was relieved and SPPs increased to 35 and 45 mmHg. Unfortunately, the tips of all her right toes turned to black (Figure 4), which resulted in metatarsal amputation inevitably. Six months later, she walked to our clinic without training wheels.
A combination with endovascular therapy and lumbar sympathetic nerve blockade could escape from major amputation for patients suffered from critical limb ischemia with poor runoff artery to below the ankle, especially concomitant with collagen disease, such as systemic sclerosis.