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Case Discussion and Live Case 1

Nachchakorn, MD.
Vascular and interventional radiology Unit, Department of Radiology
King Chulalongkorn Memorial Hospital

Sineetorn, MD.
Vascular surgery Unit, Department of surgery
King Chulalongkorn Memorial Hospital

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66 years old, Male

Patient status: Walking with no aid

2-week PTA: He developed dry gangrene of right 4th toe

1-week PTA: The wound progressively involved right 3rd toe (Rutherford class 5)

No clinical rest pain / claudication

Good morning everybody

My name is, im a vascular surgery fellow
And on my right is my wonderful colleaque doctor nachakorn, an interventional
radiologist fellow
We both here to present today first workshop case
This is a 66 year old gentleman
The patient came to us the problem of dry gangrenous change on his 4th toe which he
noticed 2 week previously
The symptoms progressively getting worse within a week
He doesn’t have any rest pain or claudication

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Past history

• Diabetes mellitus type II

• Dyslipidemia
• Hypertension
• IHD S/P CABG (2021)
• Smoking 40 pack-year, quit 10 years ago

Medication : Aspirin 81 mg, Simvastatin 40 mg, Amlodipine 10 mg, Carvidilol

As noted
The pateint has a history of DM DLP HTN
He also had IHD which he already had a bypass, done 2 years ago
He is a previous smoker and qut about 10 years ago

For his medication

heis already on 81 mg of aspirin, statin, and also some antihypertensive agents

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8/5/2023 15/5/2023

Physical examination
Right Left
FA 1+ 2+
PA 0/bi 0/bi
DPA 0/bi 0/bi
PTA 0/bi 0/mono

Toe pressure 32 36

The examination revealed

Diminished right femoral pulse
And also absent of popliteal pulse bilaterally
Signal are biphasic on both sides
Both of DPA and PTA pulse are absent with biphasic signal

Toe pressure index are significantly decreased, which are 32 on the right and 36 on
the left

The picture on the right was taken on his fisrt OPD visit
And picture on the left was taken 1 month apart
As ypu can see that the lesion was getting worse quit rapidly

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CTA

His CT angiography reveals diffuse heavy calcified plaques in aortoiliac arteries.

Moderate stenosis of both common and external iliac arteries are seen, but more
severe at the right side which correspond with the side of his wound.

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CTA

This is the run off CT angiography from other hospital.

Proximal right SFA has mild stenosis.
Distal right SFA has severe stenosis.

His proximal ATA is still patent.

But his PTA, peroneal artery, distal ATA, and DPA shows diffuse heavy calcification.
Patency cannot be well evaluated by CT.

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• Patient
• DM, HTN, DLP, IHD Average risk patient
• Status can walk without aids
• 2-year survival : 92% (VQI)  Low risk
• Periprocedural mortality: 1.1% (CRAB = 6)  Low risk
• Limb Minor tissue loss
• Wound: 2 (gangrene limited to digits)
• Ischemia: 2
• Infection: 0 (dry gangrene without sign of infection), film no osteomyelitis
• WIFI stage III

CANDIDATE FOR REVASCULARIZATION

For the patient assessment

There are 3 main key factors to be considered
First is the patient factor
Considering his u/d together with his independent status, the patient is fit for
intervention
And combining with clinical score helping to predict morbidity
VQI showed a very high 2 year survival, and also low risk for periprocedural mortality
He is an average risk patient

His limb factors

We used wifi staging system, previously proposed from the society of vascular surgery
2014
His wound classified as stage 2, ischemia stage 2 and infection 0
To group all 3 components leading us to the ultimate stage WIFI of 3

From the first 2 key factors, the patient is candidate for revascularization

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• Anatomy
 Multi-level disease
 2-staged operation
 Aorto-iliac: Endovascular-first approach
 Fem-pop region: GLASS I
 Below-the-knee region: GLASS III-IV GLASS II-III

For anatomical factors

He had disease in all of the 3 region including aortoliac, fempop and below the knee
region
We divided treatment into 2 stages
First, we correct his inflow disease, with endovascular approach
Which already did 4 weeks ago, my colleaque will elaborate on the details of the
operation after this slide

For our second stage which we will do it today

His fempop region is mild, and classified into GLASS I according to the Global vascular
guidelines proposed in 2019
For the below the knee region,
, we classified it as glass III or above

giving us Final GLASS stage at II or above

Intrigating all of the data, we use the diagram from the global guidelines

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As mentioned, his wifi score is stage III
The benefit of revascularization option would fall somewhere around here
And combine with GLASS between II or III

Indicating either bypass is a choice

or considering a surgeon with greats technical skill with high-graded device

We thimk endovascular is still a great choice for this pateint

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Angiogram 16/6/2023

• Access: Cross-over from left leg

• Aortoiliac
• Long segmental moderate stenosis of
bilateral CIA/EIA

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Angiogram 16/6/2023

• Femoro-popliteal
• Mild stenosis at proximal
SFA
• Long moderate stenosis at
distal SFA

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Angiogram 16/6/2023

• Below-the-knee
• Severe stenosis of TP trunk
• Occlusion of proximal PTA
• Multifocal mild-moderate
stenosis along ATA and
peroneal artery
• Occlusion of DPA
• Reconstitution of plantar
artery via peroneal artery

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Angiogram with stent placement 16/6/2023

• Aortoiliac
• Kissing stent at bilateral CIA
• Right balloon-expandable bare metal
stent 8x59 mm
• Left balloon-expandable bare metal
stent 8x29 mm
• Right CIA/EIA
• Self-expandlable bare stent 8x40 mm

- At right CIA: A 8x59-mm Omnilink BE BMS stent was deployed. -

At left CIA : A 8x29-mm Omnilink BE BMS stent was deployed. - At
right CIA/EIA : A 8x40-mm Absolute pro SE BMS stent was
deployed.

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Post-operation
Right Left
CFA 1+  2+ 2+ (unchanged)
PA 0/bi  1+/bi 0/bi (unchanged)
DPA 0/bi (unchanged) 0/bi (unchanged)
PTA 0/bi (unchanged) 0/mono (unchanged)

2-week follow up: dry gangrene progressed to 3rd-5th toes

of right foot

This is our planned procedural steps for today

Access is from right groin and punctured through xenosure patch

Right now, doctor Apinan and doctor punthita are already cut down rigth groin for us

After that we’ll use 0.018 wire to cross the lesion

For the CTO lesion at popliteal region, if the wire cannot pass the lesion
May be we step up to use CTO wire or
In case of failure , we plan to do a retrograde approach

For SFA segment; we plan to prep the vessel with hig pressure balloon or may be
some kinds of special balloon
And end up mainly with the DCB or stent if indicated

And finally for the popliteal CTO lesion

Vessel preparation : we also used high pressure
And end up with stent
As for this area is crossing the joint line, interwoven stent is prefered

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Procedural steps:
• Access : right groin antegrade approch
• Guidewire passage: 0.018”, 0.014”
• Distal SFA
• Vessel preparation: balloon angioplasty (POBA or specialty balloon)
• Definite treatment with DCB or bailout stent
• Below-the-knee
• Target revascularized vessel: TP trunk, ATA and PTA
• Wire passage: 0.014” with support catheter
• If failed to pass the wire: retrograde approch
• TP trunk : POBA +/- DCB
• ATA : POBA
• PTA : Atherectomy device ?, POBA

This is our planned procedural steps for today

Access is from right groin and punctured through xenosure patch

Right now, doctor Apinan and doctor punthita are already cut down rigth groin for us

After that we’ll use 0.018 wire to cross the lesion

For the CTO lesion at popliteal region, if the wire cannot pass the lesion
May be we step up to use CTO wire or
In case of failure , we plan to do a retrograde approach

For SFA segment; we plan to prep the vessel with hig pressure balloon or may be
some kinds of special balloon
And end up mainly with the DCB or stent if indicated

And finally for the popliteal CTO lesion

Vessel preparation : we also used high pressure
And end up with stent
As for this area is crossing the joint line, interwoven stent is prefered

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