Featured Case:
Dr. Pratt: 73 Year Old Female

Overview

A 73-year-old female with diabetes, hypertension, coronary artery disease, and prior stroke presented with severe leg cramps, numbness, and burning foot pain. She has an extensive history of PAD and has undergone 5 peripheral interventions in the past 2 years at a nearby facility for ischemic rest pain. She most recently underwent femoral posterior tibial bypass, but this quickly occluded.

When her cardiovascular surgeon elected to manage her rest pain conservatively, her podiatrist referred her to Modern Vascular for a second opinion. Physical exam demonstrated a cool and slightly mottled feet, and inaudible Doppler pedal signals. Additionally, the femoral pulses were not easily palpated. Noninvasive arterial studies revealed monophasic waveforms throughout the bilateral lower extremities, with toe-brachial indices of 0.17 and 0.20.

The patient was promptly scheduled for right lower extremity angiogram at our Modern Vascular facility. Given the patient’s exam and diagnostic findings, a right lower extremity angiogram was performed from a retrograde posterior tibial artery approach. Angiography and intravascular ultrasound revealed a flush occlusion of the superficial femoral artery (Image #1), a chronically occluded superficial femoral artery stent (Image #2) with reconstitution of the distal superficial femoral artery and popliteal artery. There was chronic total occlusion of the anterior tibial artery (Image #3) and dorsalis pedis artery. The occluded superficial femoral artery stent was successfully recanalized from a retrograde approach.

 

Rotational atherectomy with Boston Scientific 2.4/3.4 mm JetStream device was performed (Image #4), followed by angioplasty of the right superficial femoral artery, popliteal artery, tibioperoneal trunk, and posterior tibial artery (Image #5). The patient returned a few weeks later for a planned, staged intervention of the chronically occluded anterior tibial artery. This was performed via an antegrade right superficial femoral artery approach and consisted of atherectomy and angioplasty of the anterior tibial artery, and balloon angioplasty of the dorsalis pedis artery, anterior pedal loop, lateral plantar artery, common plantar artery, and posterior tibial artery. Completion angiogram demonstrated successful recanalization of the chronically occluded right superficial femoral artery stent (Image #6), with brisk in-line flow from the superficial femoral artery to the pedal loop and plantar arteries (Image #7). Similar two-stage interventions were performed on the left lower extremity with comparable results. At her 2-week follow-up appointment, the patient reported her feet now felt warm and that she was no longer experiencing cramps or burning pain in her legs and feet. She was able to increase her activity and even purchased a stationary bicycle to exercise. She was very satisfied with her results. She will be counseled on optimal lifestyle modifications and a supervised exercise program, and followed closely in our clinic with surveillance ultrasound studies every 3 months.