Complex Manifestations of PAD: Treatment of an Elaborate CFA-SFA-Pop-PT CTO Lesion Utilizing Various Intervention Modalities in Patients Deemed High Risk for Surgical Bypass

Introduction: Peripheral artery disease (PAD) is one of the most underdiagnosed clinical manifestations of atherosclerosis in the United States and worldwide, affecting upwards of 200 million people. Primarily involving the peripheral vasculature in the lower extremities, PAD presents initially as a silent disease but later evolves to significant leg pain, claudication, cramps, muscle atrophy, and eventual limb loss if not treated appropriately. Understanding the basic pathophysiology of PAD has led to an increase in novel techniques/development of effective treatments and interventions for this chronic illness as a notable rise in patients presenting with complex variations has been observed. For a significant number of patients, this may involve chronic total occlusion (CTO) of a vessel in the lower extremity, leading to gangrene and eventual amputation if not treated promptly. In this case study, we explore the utilization of multiple intervention modalities to restore normal function to existing vasculature affected by a long complex left superficial femoral artery (SFA) CTO lesion in a patient deemed high risk for surgical bypass.

Case Presentation: A 64-year-old man with a history of hypertension, dyslipidemia, heavy tobacco habituation, stage IVa laryngeal cancer, and Rutherford class IV PAD in the left lower extremity s/p common iliac and SFA stents presents with severe left leg pain that has progressed for the past 4-6 weeks. Review of left leg arterial doppler was suggestive of his left SFA stent reocclusion and limited flow in the posterior tibial (PT). A peripheral angiogram was performed, revealing a substantial CTO of the left ostial SFA, with thrombus throughout the stent, stretching into the popliteal artery and below-the-knee vasculature. After adequate assessment, 2 separate interventions were performed using multiple techniques including laser atherectomy, mechanical atherectomy, percutaneous transluminal angioplasty (PTA), and placement of 12-hour EKOS device (Boston Scientific) and 5 Viabahn stents (Gore) throughout the long lesion. In conclusion to the various intervention strategies performed, severe CFA-SFA-popliteal artery with thrombotic lesions s/p mechanical thrombectomy and PTA displayed significant improvement. Additionally, there was successful stenting of the distal SFA-proximal popliteal artery and PTA of the severe PT disease was excellent.

Conclusion: By and large, the prevalence of complex PAD cases has greatly increased over the years as the chronic illness continues to remain historically underappreciated by health care professionals and patients. Though new interventional modalities are key to successfully treating complex PAD as seen in this patient with an elaborate SFA CTO, early detection and prevention of PAD are crucial to combat the increasing numbers of complex manifestations. This seemed to be a viable option in patients deemed to be at high risk for surgical bypass.