Author + information
- Jeehoon Kang1,
- Chang-Hwan Yoon2,
- Si-Hyuck Kang2,
- JinJu Park2,
- Jung-Won Suh2,
- Young-Seok Cho2,
- Tae-Jin Youn2 and
- In-Ho Chae2
Patient initials or identifier number
Relevant clinical history and physical exam
This 74 year-old male visited SNUBH with progressive claudication (both legs, left leg more severe) since 5 years ago. He was admitted for percutaneous transluminal angioplasty (PTA) for peripheral artery disease and initial PTA showed improvement in the l Ankle-Brachial Index(ABI) test. However, symptoms of chronic limb ischemia did not improve, and due to aggravating toe ulcer and gangrene, toe amputation was planned. However, before amputation, the patient was re-admitted for a second PTA.
Relevant test results prior to catheterization
The Initial ABI test showed a low left ABI (right 1.04 / left 0.55) and low both Toe-Brachial index (TBI) (right 0.63 / left 0.37) CT angiography of lower extremity showed diffuse atherosclerotic change with calcification in aortoiliac arteries, short segmental severe stenosis at left external iliac artery, patent both SFA occlusion of right ATA, but patent PTA and peroneal artery. ABI after the initial PTA showed normal ABI values (right 1.10 / left 1.11).
Relevant catheterization findings
Before initial PTA,the patient underwent coronary angiography, and PCI was done for LM-LAD disease (Osiro 3.5 × 22 mm). Initial PTA was done for the tight left external iliac artery (Stenting with Absolute pro 8.0 × 80 mm).
A PTA done by antegrade approach via both femoral arteries. Peripheral angiography for the left leg showed stenotic and calcified left ATA and PTA. The left PTA was totally occluded immediately distal to the PA-PTA bifurcation site (Figure 1A, arrow). By support with a CXI catheter, Regalia 300 cm advanced and POBA was performed to the left PTA and left ATA. Angiography performed to show patent distal flow to the left foot (Figure 1B). Peripheral angiography for the right leg showed a stenotic right PTA, PA and the right ATA was total occluded distal to bifurcation site (Figure 2.A.). Due to the severely calcified ATA, a retrograde approach was performed by the PTA, planter artery and dorsalis pedis artery to the ATA (Figure 2.B.). A loop formed using a micro-snare to pull the retrograde wire. Afterward, multiple POBA was done with Amphirion deep 2.0 × 120 mm and Nanocross 2.5 x 210 mm (Figure 2.C.). Final angiography showed restored flow to the left ATA and excellent perfusion to the right foot (Figure 3A, 3B).
The patient was discharged with no acute complications. During the follow-up period, toe ulcer on both feet showed clinical improvement with decreased pain on ambulation. The planned bilateral toe amputation was canceled and medical treatment with dual antiplatelet agents is in progress.
This is a case of successful PTA for a patient with CLI and a normal ABI value. Initially, PTA was planned based on symptoms and a low ABI value. After PTA for the left iliac artery, ABI values improved, but symptoms of CLI persisted. Medical follow-up was planned, and the patients’ symptoms were thought to be accounted cholesterol emboli. However, symptoms and signs of limb ischemia aggravated, and the patient was threatened by toe amputation. A second PTA was done to salvage the patient's toe, leaving in successful results. Symptoms and signs of limb ischemia should be considered before a normal ABI index, especially in peripheral artery diseases small below-the-knee arteries.