Dr. Anthony Pozun: 75- Year Old Vietnam Veteran
This week’s Modern Vascular featured case comes from Dr. Anthony C. Pozun, DO, Board-Certified Interventional Cardiologist for Modern Vascular in Glendale, AZ.
CH is a 75-year-old Vietnam veteran and patient of Modern Vascular for over 3 years. He has a history of peripheral vascular disease, coronary artery disease, atrial fibrillation, diabetes, Parkinson’s disease, hypertension, PTSD and dyslipidemia While serving in Vietnam, he was exposed to Agent Orange, for which he is service-connected through the VA Medical System. His outpatient medications include Januvia, insulin, Xarelto, pravastatin, low-dose aspirin, digoxin, furosemide, carbidopa-levodopa, levothyroxine, pantoprazole, benazepril, and bupropion.
This patient originally came to Modern Vascular for severe lifestyle-limiting peripheral vascular disease at the end of 2019. In December of 2019, he underwent intervention to the left lower extremity. In February of 2020, he underwent intervention of the right lower extremity. Both interventions included atherectomy of the anterior tibial and posterior tibial arteries along with the pedal plantar loop.
CH remained pain-free and able to walk for about 2 years after these interventions.
Then, over a period of 9 months, numbness and claudication resumed. By November of 2022, the patient developed severe recurrent lifestyle-limiting claudication, rest pain bilaterally (Rutherford 4), severe neuropathy, and discoloration and early gangrene of the right first toe. In the patient’s words, he felt “a gremlin going after his feet with an ice pick” at night. His feet became ice-cold. He stated he had to use a scooter for shopping because “the leg pain starts almost with the first step.” He failed a dedicated walking program.
Due to these symptoms, lower extremity arterial Doppler was performed, revealing occlusion of the proximal and mid right anterior tibial artery, subtotal occlusion of the right posterior tibial artery, 20-49% stenosis in the right popliteal artery and monophasic low resistant waveforms in the right dorsalis pedis artery. Heavy calcification was noted throughout the intima. The left anterior tibial artery was 100% occluded with retrograde flow in the left posterior tibial artery and high-grade stenosis. Collateralization of the distal posterior tibial artery was visualized as well. ABI on the right was 1.22 due to calcification with a TBI of 0.78. ABI on the left was falsely elevated at 1.36 due to heavy calcification with a TBI of 0.68. Physical exam revealed nonpalpable pulses in the lower extremities bilaterally with monophasic waveforms of the right dorsalis pedis and posterior tibial arteries along with the left dorsalis pedis and left posterior tibial arteries. Early gangrene of the right first toe was noted. Absence of hair in lower extremities was also noted. Capillary refill was greater than 3 seconds.
The patient was scheduled for right lower extremity angiography on December 28, 2022. Attempt to gain access in the right dorsalis pedis and posterior tibial arteries was unsuccessful due to severe occlusive disease. A 6 French sheath was placed in the right superficial femoral artery antegrade. Selective angiography of the right lower extremity with digital subtraction revealed moderate disease of the distal right superficial femoral artery and right popliteal artery. There was moderate to severe diffuse disease of the right tibial peroneal trunk. The right anterior tibial artery was 100% occluded 10 mm after the ostial takeoff. The right peroneal artery was the only dominant vessel below the knee. The right posterior tibial artery was occluded shortly after its takeoff. The distal right peroneal artery reconstituted the distal anterior tibial artery via an anterior communicating branch and there was severe disease in the right dorsalis pedis and pedal portion of the pedal plantar loop. The distal posterior tibial artery and common plantar artery were both filling from the peroneal collaterals. There was moderate to severe diffuse disease of the pedal plantar loop along with poor visualization of metatarsal branches.
Patient received 7000 units of intra-arterial heparin. Digital subtraction angiography was performed creating a roadmap for the takeoff of the right posterior tibial artery. Cannulation of the ostial posterior tibial artery was performed first using an angled 4 French Bernstein catheter. This was exchanged out over a 0.035 inch Bentson wire for a 90 cm Navicross catheter. Advancement of the catheter and wire was performed in tandem with successful wiring of the posterior tibial chronic total occlusion and eventual positioning of the wire and catheter in the reconstituted distal posterior tibial artery/common plantar artery. Selective angiography was performed to confirm intraluminal placement of wire and catheter. The 0.035 inch Bentson wire was then removed and exchanged for a 0.014 inch Savion wire. This wire was advanced to the pedal plantar loop retrograde up into the dorsalis pedis artery. Attempt was made to cross the distal anterior tibial occlusion with the assistance of a 2.0 x 40 mm Coyote balloon but was unsuccessful. Intravascular ultrasound was then performed of the right SFA, right popliteal, right tibial peroneal trunk, posterior tibial artery and the pedal plantar loop. Intraluminal wire position was confirmed. The tibial peroneal trunk measured 2.5-2.75 mm with greater than 70% stenosis. Chronic occlusion was noted throughout the posterior tibial artery with the vessel measuring 2.5-2.75mm proximally. There was severe, greater than 80% stenosis in the common plantar and lateral plantar arteries by IVUS. Laser atherectomy of the right tibial peroneal trunk and entire posterior tibial artery was performed using a 1.5 mm Auryon catheter with full recanalization. Balloon angioplasty of the pedal plantar loop was then performed using a 2.0 mm x 220 mm Coyote balloon for two minutes. Balloon angioplasty was then performed of the tibial peroneal trunk and posterior tibial artery utilizing a 2.5 mm x 220 mm x 150 cm for two minutes. Repeat angiography revealed full recanalization with less than 10% residual stenosis.
The 0.35 mm Bentson wire with the 90 cm Navicross was then advanced back down into the ostial anterior tibial artery, and wire and catheter were both crossed with minimal resistance through the chronic total occlusion. Intraluminal wire position was confirmed angiographically with the Navicross being positioned in the distal anterior tibial artery and the dorsalis pedis. The Bentson wire was removed and exchanged back out for the 0.014 inch Savion wire. IVUS of the right anterior tibial artery was then performed confirming complete intraluminal positioning with the proximal anterior tibial measuring 2.75 mm, 2.5 mm in the mid segment and 2 mm in the distal anterior tibial segment/dorsalis pedis. Dorsalis pedis revealed greater than 80% stenosis by IVUS. The 1.5 mm Auryon laser catheter was then advanced into the proximal anterior tibial and laser atherectomy of the entire anterior tibial vessel was performed. This was removed and exchanged for the same 2.5 mm x 220 mm x 150 cm Coyote balloon; angioplasty was performed for 2 minutes. Repeat angioplasty of the pedal plantar loop was not necessary antegrade through the anterior tibial artery. Selective angiography of the pedal plantar loop was then performed (before and after imaging shown below). Repeat angiography was then performed of the popliteal and infrapopliteal vessels (before and after images shown below).
There were no complications during the procedure. A 6 French Angio-Seal was deployed to the right superficial femoral artery with adequate hemostasis. In recovery, patient already had increased sensation in his foot. He was discharged home on current outpatient medications including Xarelto 20 mg daily with ASA 81mg daily.
Two weeks after this most recent revascularization of the right leg, CH reports no symptoms in the right leg and is ready to proceed with revascularization of his left leg.
About Modern Vascular
Dr. Anthony Pozun is a board-certified interventional cardiologist currently providing services at Modern Vascular in Surprise, AZ. Modern Vascular is a group of fifteen outpatient clinics across AZ, CO, IN, KS, KY, MO, MS, TN, TX specializing in the treatment of peripheral artery disease (PAD) through minimally-invasive endovascular procedures. Between Modern Vascular’s state-of-the-art equipment and highly trained specialists, its doctors are able to revascularize all the way to the toe. Most patients report reduced pain, faster healing in the area treated, and a better quality of life post procedure. For patients with chronic limb-threatening ischemia, Modern Vascular’s revascularization procedures have also been the key to saving a limb from amputation when there are few options left.
For more information on PAD, Modern Vascular’s office in Surprise, or to schedule an appointment, please visit https://modernvascular.com/clinics/surprise/ or call 1-833-4PAD-HELP to speak to a Patient Advocate.
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