Endovascular Approach After Occluded Surgical Bypass: Last Option Limb Salvage Case Presentation

Purpose: Critical limb ischemia (CLI) affects approximately 1 to 2 million people in the United States. One-year mortality after CLI diagnosis and amputation is 40%. This case presents a 71-year-old man with a history of peripheral arterial disease, hypertension, and dyslipidemia who is very active golfing daily. He had a wound to the medial aspect foot, first metatarsal that had not healed and was worsening to the point where he could not golf. He had undergone 2 surgical revascularizations with a fem-fem and fem-pop bypass by 2 different surgeons in 2018 and 2021. At his last visit, below-knee amputation was recommended as the only option. His wound care specialist became concerned when this wound was not responding and referred the patient to Dr. Laiq Raja for a second opinion.

Materials and Methods: The patient was taken for angiogram in April 2021 and found to have a totally occluded arteriofemoral bypass to the right limb. Dr. Raja was able to revascularize the native anterior tibial artery and performed mechanical thrombectomy with infusion of tPA to the right fem-pop bypass with subsequent stent placement to the proximal anastomotic site of the right fem-pop bypass and percutaneous transluminal angioplasty and stent placement to the distal anastomotic site of the right fem-pop bypass. After this procedure, his wound began to heal well; however, in September 2021 he presented with severe pain. He called the CLI nurse practitioner navigator, was seen urgently in the office, and was subsequently directly admitted for treatment of the thrombosed occluded bypass. He underwent percutaneous transluminal angioplasty and revascularization of the chronically occluded posterior tibial artery and tPA infusion to the fem-pop bypass graft using an EKOS catheter (Boston Scientific) retrogradely. He was discharged on aggressive anticoagulation and followed very closely; however, he did reocclude in December 2021 and underwent one more intervention to treat thrombosed fem-fem and fem-pop bypass grafts successfully.

Results: The patient is followed closely and reaches out to the CLI navigator with any concerns urgently. His wound is now completely healed and has continued to do well. He has maintained close follow-up with our team and continues to golf several times a week and follows with wound care as needed for offloading. The team communicates on his care plan often.

Conclusions: Treatment of CLI requires advanced endovascular intervention and a multidisciplinary team with close follow-up and good communication as well as rapid response when there is a setback. By educating patients on this process, we can intervene in an urgent manner and prevent further tissue loss, allowing for continued healing and resolution of wounds.