Endovascular Limb Preservation: Critical Limb Ischemia From Single-Vessel Runoff to 3-Vessel Flow

Purpose: Critical limb ischemia (CLI) occurs when there is severe blockage of the arteries causing persistent resting pain, nonhealing ulcers, or gangrene. CLI affects approximately 2 million people in the United States. This causes a 60% readmission rate within 6 months of a hospital discharge; most will die or have a major amputation in the first year. This case presentation demonstrates the collaborative approach to limb restoration through advanced endovascular procedures, wound care, and patient education. We present a 65-year-old man with a nonhealing ulcer on the left foot, severe peripheral arterial disease (PAD) with CLI, and a recent digit amputation. The patient was hospitalized and offered only a below-knee amputation; however, he signed out against medical advice to acquire an alternate opinion and attempt on saving his leg.

Materials and Methods: The patient underwent an angiogram, which revealed extensive disease of the superficial femoral artery with 20% stenosis with calcification, 60% stenosed popliteal, 80% peroneal, and 100% occluded anterior tibial (AT) and posterior tibial (PT). There was an ostial occlusion of the PT artery with reconstitution at the plantar arch. Given the patient’s nonhealing ulcer, in addition to severe PAD and CLI, the decision was made to proceed with intervention for limb restoration. A catheter was advanced to the AT and across the entire occlusion and into the distal vessel, the wire then was advanced around the arch and retrograde up the PT vessel. The wire was advanced across the CTO of the ostial PT. At this aspect, a second wire with catheter was advanced to the PT artery and across the lesions into the distal vessel in an antegrade fashion for support; IV ultrasound was performed.

Results: Atherectomy was performed using the Auryon laser 0.9-mm device (AngioDynamics). Balloon angioplasty was done to the AT, PT, popliteal, and peroneal arteries. There remained a flow-limiting dissection in the mid-AT and popliteal arteries. Given the prior amputation and nonhealing ulcer, the decision was made to stent the vessels to provide maximum opportunity for wound healing and limb preservation. There was now excellent 3-vessel flow down into the foot and filling both the dorsal and plantar arch.

Conclusions: After successful revascularization, the patient is healing. This case demonstrates the importance of quick follow-up and diagnostics to determine appropriate methods for limb restoration. The patient in-clinic education on PAD signs and symptoms saved life and limb.