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Patient initials or identifier number
Relevant clinical history and physical exam
We present a 71 year-old man, known for diabetes, hypertension, dyslipidaemia and heavy smoker, suffering from bilateral claudication from several years but without any previous diagnostic investigation. Not known for other important diseases. Several hours before admittance in the hospital he referred severe left leg pain as the reason to bring him to our emergency room (ER).
Relevant test results prior to catheterization
In the ER the general haemodynamic, respiratory and laboratory, parameters were within the normal range. The left leg, particularly below the knee, where the patient referred pain and paraesthesia, was poikilothermic, pallid and pulse less. His left leg ABI index was 0.12 and immediate arterial color Doppler revealed occlusion of the left femoral superficial artery (SFA), some flow in the distal part and no flow in the tibial arteries. Thus, he immediately referred for urgent angiography.
Relevant catheterization findings
Angiography through 4F right radial artery revealed occlusion of the left superficial femoral artery (SFA). Through collaterals the distal SFA, the popliteal artery with significant stenosis and the tibial-fibular trunk visualized. The both anterior (ATP) and posterior (PTA) tibial arteries were occluded and the fibular artery was occluded at its middle part. There were some visualization of the dorsalis pedis artery (DPA) and the ankle part of the posterior tibial artery (PTA).
A second puncture in the right brachial artery (6F introducer) was performed and with a 0.35” polymer wire the occlusion of the left SFA passed. After several predilatation a self-expandable stent was placed using the radial approach for contrast control. Then a third puncture above the released stent made and a 4F anterograde introducer placed.Unsuccessful anterograde tentatives to reopen ATP, PTA and fibular artery were made, and then forth retrograde puncture of the DPA under X-ray control with contrast medium was made. With a Filder 0.14” wire retrograde the ATA occlusion was reopened and the wire was captured inside the 4F catheter with balloon inflated inside. The wire externalized through the 4F anterograde femoral introducer. The ATP fixed by several POBA with drug-eluting balloon (DEB) inflations and one drug-eluting stent at its ostium. The retrograde 4F sheath from the DPA removed with 2 mm balloon inflation. Then a Filder 0.14” wire with the support of OTW balloon through a small collateral from the fibular artery was directed retrogradely to the proximal part of the same artery and was retrieved using a snare through the anterograde SFA 4F introducer. The fibular artery anterogradely reopened with POBA with DEB. Control anterograde angio demonstrated good flow through SFA, poplitel, fibular and ATA with good distal perfusion.
The Endovascular treatment of critical limb ischemia can be an exceedingly challenging and complex problem. Technical success rate and clinical outcomes, with a high rate of limb salvage and amputation-free survival are encouraging. Thus, the endovascular revascularization as the first treatment option demonstrates that is a reasonable and effective approach. Usually only one technical strategy is not enough to treat complex situation to improve the results of the procedure. Maximal effort should be made to reopen as much as possible arteries when we talk about the critical limb ischemia.