Dr. Broadway: 66 Year Old Female
Featured Case Overview
A 66 yo woman with congestion heart failure, diabetes mellitus, type 2, hypertension, coronary arterial disease and renal insufficiency. She presented with complaints of multiple punctate heal ulcers. She had significant pain causing her to walk on her toes. She had rest pain in the right foot and states she could not bear it anymore. On physical she had monophasic dorsalis pedis, non doplerable posterior tibial and anterior tibial. She had 2+ CFA and non-palpable popliteal arteries. She had a quarter sized ulcer of her left hallux. She had 5 quarter sized to dime sized ulceration of her lateral heal. She had delayed capillary refill. Selective antegrade right lower extremity angiogram using CO2 demonstrated chronic total occlusion involving the P1 and P2 segments of the popliteal artery, segmental anterior tibial artery and full posterior tibial artery. She underwent intervention at that time performing successful recanalization of her P1 and P2 segment popliteal artery with Hawk One atherectomy and balloon angioplasty. The antieror tibial artery was recanalized using angioplasty over an 0.14 wire. An attempt was made to recanalate the posterior tibilal artery proximally resulted in extravasation. The 0.14 wire was then taken through the dorsalis pedis and around the anterior pedal loop into the occluded lateral plantar artery. At this point a fistula was created off the lateral plantar artery into the lateral plantar vein. Prolonged angioplasty was performed.
Progression of wound healing
Post angioplasty fistulogram in the anterior tibial artery demonstrated filling of the deep plantar artery and lateral plantar artery in the posterior tibial vein. Immediately the patient stated her pain had dissipated. On three month follow up the ulcers are nearly completely gone. The fistula remains open. This case demonstrates treatment in chronic limb ischemia has many options and amputation should be the last resort. It’s important to note that patients with stage three renal insufficiency can be performed at the office with the use of Intrasvascular Ultrasound and CO2 angiography limiting the amount of iodinated contrast. As in this case total of 13 cc of contrast was utilized.
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