Featured Case:
Dr. Bhatti: 60 Year Old Male

Overview

A 60-year-old male with a past medical history of Type II Diabetes, 5 previous myocardial infarctions status post coronary artery stenting, and kidney transplant presented for a second opinion after being told he will require a below-the-knee amputation. He has a surgical site nonhealing wound present since he underwent right hallux and second digit amputation 5 months ago. He also has ischemic changes involving the remaining toes with necrosis at the tip of the right third toe. Due to the nonhealing wound and pain within the right foot, he is no longer ambulatory. Of note, the patient has undergone 6 prior angiograms at another facility, during which time his iliac arteries were stented and angioplasty of his superficial femoral artery performed; his tibial arteries were never treated and he was told that distal revascularization was impossible. Angiography of the right lower extremity showed multifocal stenoses ranging from 70-90% involving the superficial femoral (SFA) and popliteal arteries. More critically, however, all of his tibial arteries were occluded and he had minimal blood flow to his foot. Wound-directed revascularization was undertaken. Given his posterior tibial artery was occluded at its origin, the occluded common plantar artery was accessed and the posterior tibial artery recanalized in a retrograde fashion. Wire access was then reversed and recanalization of the common and lateral plantar arteries and anterior pedal loop was performed. This was followed by balloon angioplasty of the SFA and popliteal artery stenoses. Then, atherectomy, followed by balloon angioplasty, of the posterior tibial, common plantar, and lateral plantar arteries were performed. Finally, the anterior pedal loop was treated with balloon angioplasty. Completion angiography showed brisk inline flow to the foot with perfusion of the wound bed and remaining toes. Of note, due to the patient’s history of a renal transplant, only 6 cc of contrast was used for the entire procedure. The use of intravascular ultrasound (IVUS) allowed us to achieve an optimal outcome without sacrificing visualization. The patient is 2 weeks status post revascularization. His wound care physician

reports his foot is now warm and that his wound has undergone interval healing. He will continue to be followed in our clinic to ensure lifestyle factors and medical therapy are optimized from a vascular standpoint.