Chapters Transcript Vascular Surgery and Non-Healing Peripheral Wounds Vipul Khetarpaul, MD, presents several cases on PAD and Non-Healing Peripheral Wounds. Great. So um I am gonna go ahead and introduce you and then you can take it from there. So, our next presenter is Doctor Vipul Karpal. He earned his medical degree at Fura Medical College in Minal Indi India. He then completed his residency in general surgery and his fellowship in vascular surgery at Washington University School of Medicine. He is currently an associate professor of vascular surgery and sees patients at Christian Hospital, Berlin Salvage using both minimally invasive and endovascular and open surgical techniques. Um stroke and carotid disease, aortic aneurysms and dissections, peripheral dialysis, access varicose veins. And I'm sure much more. I think those are just a couple of things we wanted to mention. But um thank you so much for your time today and I will let you present now. Oh, thanks Nicole. Um So I wanna talk to you all about uh role of vascular surgery in evaluations of CLT I patients, which is chronic and threatening ischemia. I do not have any disclosures. We all run across situations where we encounter di diabetic hypertensive patients who are smokers who show up with long history of claudication with new wounds all the time. They have weak pulses on exam and then they show up and they wanna discuss P ad care with all of us. So every evaluation for us starts with the history and physical because a lot of times just based on history and physical alone, we can determine the level of occlusions for a lot of these patients with significant PV D. For example, if they show up with a lot of thigh and hip claudication where they hurt to walk and their tire butt hurts after a certain distance consistently, uh you could assume ao iliac pathology. So it's always one level down where uh occlusion is uh going to lead to symptoms. So, if somebody comes in with calf claudication, it's oftentimes s fa public tal segment that is diseased, uh ulcer type, uh arterial ulcers are oftentimes, terminal ulcers. So, toes, um or uh wherever you have end organ, uh single digital arteries is where you would see those ulcers, venous ulcers are oftentimes close to the ankle and neuropathic culture or pressure ulcers are on dependent uh areas. Um in terms of medical management, uh he tried to risk stratify them from a cardiovascular standpoint and uh make sure that they're on a high statin high potency statin to uh treat the their uh hyperlipidemia. Even in patients who do not have significant hyperlipidemia. Statin therapy has been shown to reduce the overall inflammatory uh load in their body to help with their P ad progression uh more recently in the last few years. Um uh we have started using low dose Xarelto that is 2.5 mg, Xarelto B ID dose along with baby aspirin for a lot of these patients, which has been shown to be uh very beneficial from a cardio vs sort of mortality and morbidity standpoint per voyage or trial. Uh I selectively use Pletal trial uh in a lot of my cloud patients who have normal LV function to help with their Claud medication distance. And most importantly, smoking cessation uh is very critical for long term management of P AD patients. CLT I presents with a wide uh in a wide variety of ways. It ranges anywhere from having a neuropathic culture that's not healing to toe gangrenes as we discussed, are completely modelled uh ischemic legs which are beyond salvage. Uh So we have to uh uh evaluate uh these patients based on their presentations. Uh critical limb ischemia oftentimes presents with cool hairless uh limbs. Uh They have ischemic metatarsalgia, they have ischemic alterations or gangrene. As we saw in the previous picture. If you were to get an A B I more often than not, their A B is in 0.4 range or less, it can be elevated in certain conditions which have significant tibial and pal calcification like diabetes and E SS RD, oftentimes their ankle pressures are less than 50 I expect their toe pressures to be less than 30 for a patient to be able to uh heal their wounds, to uh to put things in perspective, you want the toe pressure to be at least over 50. Um Then we have Rutherford classification for presentation um um for C LP I which ranges anywhere from ischemic wrest pain to category five, which is minor tissue loss or six, which is major tissue loss where limb cell which is no longer feasible. And you have to consider uh doing major amputations in the last 10 years. We now have been equipped with Wi Fi staging, which takes it to the next level because historically, we used to think of wounds only in terms of limb ischemia, but in terms of A B, but as we all know, it takes more than just poor blood flow to predict whether is gonna heal or not. So this classification takes into account how extensive the wound is uh along with the degree of ischemia based on A B I and toe pressures. And lastly infection plays a huge role uh in uh uh predicting whether these wounds are gonna heal or not. So, as you can imagine if the ischemia or the degree of wound is on the higher side, you have a higher risk of major amputation at one year compared to someone who's not ischemic. And the wound is uh minor. Similarly, based on Wi Fi staging, you can also predict whether somebody is gonna benefit from revascularization or not So we triage these patients based on Wi Fi scores where if they have a significant degree of ischemia, uh and a significant degree of wounds where people would benefit more from revascularization versus some of the terminal ends. Uh in terms of infection, uh where they would not benefit from any of these uh interventions. Uh There is a simple SVS uh app that everyone can download to help figure out the Wi Fi stage that helps you triage whether these patients would be amenable to uh revascularization and benefit from it. Almost everyone has access to uh a simple Doppler in their office. So even though uh testing time is not available, we can simply screen them in our office with blood pressure cuffs uh to measure uh an A B I if formal testing is not available. Uh It's an indirect measure of uh what the uh blood flow should look like uh in a, in a periphery above 0.9 is normal 0.7 0.9 but indicate mild obstruction in the arterial tree. 0.42 0.7 is moderate reduction uh and less than 0.4 is severe. So anytime the A B I is less than 0.4 we are generally very concerned, particularly if the A B I is less than 0.3. And it's measured based on the highest ankle pressure between A T and PT uh divided by highest uh brachial plus pressure. So suppose one of one of these patients comes in with a bi a lot of times we get the question, what is the most sensitive uh test to predict wound healing? Well, we have a lot of tests at this point in time that are available to us ranging from T coms where uh which a lot of wound care centers are now using, who are equipped with hyperbaric oxygen T CPO two, we have spy camera uh which detects perfusion to uh the feet or toe pressures which we routinely use. And then lastly, we have the RT O duplex angiogram or CTMR Angio or pet. None of these options are perfect in terms of evaluating uh uh blood flow as I would uh uh show you in the next few uh cases. This is an example of a 69 year old patient with diabetes CKD who had the right BK A and presented with left the foot, nonhealing wounds for two years. They had a negative biopsy for infection negative Venus work up even though the distribution was kind of concerning and also had this uh little healed wound and you know, questionable palpable pulse like a weakly palpable something but the Doppler was completely normal. So under normal circumstances, I would say this person does not need an angiogram because their toe pressure was pretty decent. The Doppler waveforms look pretty decent but something wasn't right because they had everything else negative and they were still not able to able to heal this wound despite negative infectious work up and RT L and Venus work up or the rudimentary RT L work up. So I decided to do an angiogram on this patient. And lo and behold, it showed pop artery CTO uh right across this segment. There should be a pop artery going straight across and instead he was feeding everything off of the single collateral. So we were able to get through this and perform signal arty, which means that we removed a bunch of plaques from this segment and used a drug coated balloon to reduce om hyperplasia. Uh This is 10 months later where everything is still uh looking painted and subsequently, the patient uh got skin graft which completely healed uh his wounds. So, you know, AAA competent team approach for limb cell, which is extremely critical to taking care of these patients where uh the wound care center, our service line from vascular surgery and plastic surgery all work together to help achieve this goal for this patient. So as a vascular surgeon, what would I want done before seeing a patient with critical lymph threatening ischemia? I would say the most important thing for any of these patients is early referral because the longer we wait, the higher the chance of infection setting in or a gangrene setting in which would make the treatment uh algorithm even more complex. Um My personal goal for our office is to try to see them within five business days. So at least we can set up at least an angiogram or something simple, but or an evaluation within 10 days, um I would suggest at least getting an A B I with toe pressures along with arterial duplex as a as a fundamental evaluation at the time of referral. Uh So that uh it gives us a basic outline of where the disease process is and what could be done for them. Generally speaking, if common femoral artery is easily palpable, this much work up is adequate for a starting point and we can take it from there and do an angiogram next. But in my practice, if I don't have a strongly palpable common femoral pulse, and I'm suspecting aortic disease or iliac disease. Uh I generally get AC T A or an Mr A uh to help understand the inflow disease because the treatment algorithm for that may require hybrid intervention or a big open surgery uh rather than something simple. Um But whenever in doubt, uh seek help early to help address these patients needs the treatment for cli in my mind. Uh it's uh uh very critical and almost always required. Uh If someone has significant uh lim ischemia uh without uh a feminine infection or a contractor limb or excessive tissue loss, you almost always need to do something for these patients. Now, whether that intervention is a surgical bite past uh or uh something endovascular, I think that choice is best made by an interventionist who has uh both options available to them. So, vascular surgeons are perfectly suited to answer the need for all D CLI patients because we can offer them surgical bypasses or endovascular interventions. As VC fed based on their particular needs, all open interventions uh are based on simple fundamentals. You need a good starting point in terms of inflow where the artery is normal, you need a good outflow vessel where the vessels are gonna be normal after the blockages and then you need to pick a conduit. Ok. So we always keep in mind that there are certain segments which are no stem zones which are flexion points like uh p femoral arteries. Sometimes you avoid stents across the joint space and public tal arteries. But now we have better stents that, that do well in this, this section also. Uh and then kind of tailor the treatment options based on their particular needs for a conduit options. We have a wide variety of uh materials available ranging anywhere from go tex ring graft which are reinforced with these uh rings to prevent compression to traditional Dacron graft. This is an example of an aortobiiliac uh graft. Uh This is anastomosis below the kidney art below the renal arteries and lower down it's an N two and anastomosis to the common iliac arteries. We have now cryo uh cadaver arteries and vein grafts. We have boba and arty graft. Uh We have Sains uh obviously uh as a great uh uh bypass uh conduit, there is new technology emerging in form of human site which are artificially grown um conduits from human cells. But right now, they're kind of limited in terms of length. So we're not using them for peripheral bypasses at this point in time, but they can be used in infected fields for short segments. This is an example of a 60 year old male with the impotence and bilateral tie and hip notation who had absent femoral pulses with new uh wound on their feet. On the reconstruction, you can see that the occlusion starts at the level of the renal. The common femorals are occluded right here uh uh on the on both sides with occluded, hypogastric arteries. So, in terms of outflow, at the very least at the level of the groins where the vessels are occluded, we need to do what's called a common femoral andoy where we open up the arteries longitudinally and then remove all of the plaque and core out all of the plaque from the inside and then repair the artery but some sort of a patch to keep it from re narrowing down to a small lumen. And then we figure out how to best get them better flow. So whether the best flow that we can achieve for this patient is with an anti an anastomosis below the renal artery or an icy anastomosis below the renal artery. And then running conduits down would depend on whether or not they have patent vessels in the segment below. So for example, in this case, everything below the renal arteries were occluded. So it would probably be an end to end anastomosis at the top because we don't need to reperfus an inferior mesenteric artery or a bunch of lumbar arteries below that segment. What if this patient was very sick and cannot tolerate a big open operation? Then we explore other options for bypasses which are axillary to femoral bypass and then cross over femoral to femoral bypass graft. So these are extra atomic bypasses. The patency of these bypasses uh is not as robust. It's in the 50 to 75% range versus close to 95%. Uh patency rate for aortofemoral or iliofemoral bypasses. So we tried to do in line reconstruction for the shortest segments in form of a Tomor bypasses rather than extra an atomic bypasses whenever we can. So I'm gonna leave you with some thoughts that while these options are great and we can entertain these big surgical bypasses for a lot of these patients. Every now and then you run into situations like this where you have a 75 year old lady with diabetes CKD. Her BM I is 60 her A B I is only 0.1 five and she has tissue loss. You get AC T scan on her and she has got an external iliac occlusion, her entire superficial femoral artery in her thigh is occluded and she has failed endovascular intervention at some other place and has been turned down by multiple vascular surgeons and cardiologists at other hospitals. Due to her complexity on the CT scan. Her common femoral artery is 16 centimeters deep from the skin. Uh but at least the profunda outflow is open. So this is her angiogram. This is the common iliac artery, hypogastric artery, external iliac artery should live right here and it's completely occluded. This is her femoral head and her common femoral artery is included as well along with uh S FA which should be right around here. So sorry and on delayed images, the common femoral comes back but the S fa is occluded, the superficial femoral artery should be right here and it's completely occluded and she comes back below the knee, uh above the knee and the pial artery. Uh these images seem grainy even though they are from the hybrid room. So she her BM I is again 60. So doing anything for a patient like this is tough. So maybe this is, would this patient get a bypass or not? We'll come back to it for infra inguinal disease. We have options of doing fem pop bypasses. So again, same concept, you start with a good uh inflow segment which is a common femoral artery and run a bypass beyond the occluded uh S fa public lottery segment and run it down to a patent tibial vessel or a patent pal vessel. And you can do other adjuncts at the time of this intervention for inflow, which includes things like Profunda Plasty, which means patching on to the Profunda to keep at least the Profunda open. In case the bypass were to include in the future. Femoral and arthrectomy as an influence intervention for PV D is uh pretty good, but the patency of at least 90% at five years. So we are very liberal with its use when it comes to doing bypasses. Though we tend to be less liberal with their use uh for Cloudant. However, for CLT I, we are very aggressive with the use of uh bypasses. Uh Recently, uh best cli trial got published that showed that uh fem fem pop bypasses uh with vein where the single segment vein is adequate is far superior than any endovascular intervention is even as a first line intervention. So all low risk patients, we are considering a lot of MP bypasses with vein for cot I patients rather than endovascular first. If they do not have good vein, which is which happens more often than not, especially in the population that we are serving in North County. Then a lot of those patients are getting endovascular first intervention still as you can tell any segment uh with vein bypass has great patency here. But soon as you start going to prosthetic bypasses uh below the leg, their patency starts dropping down. Um again, vein vein bypass patency for cli with tissue acids, about 75% with excellent limb salvage rate of around 88% when it comes to endovascular tools. And considering what tools are available to us, they range anywhere from balloon angioplasty, which is uh just ballooning, the segment of occlusion to plaque modification tools that we'll discuss some more. And finally stent angioplasty balloon angioplasty. Now has options with different kind of drugs that can be delivered ranging from croy to paclitaxel. Paclitaxel data is well known. And now we have crom co Ball as well in that technology. Plain old balloon angioplasty for segments of a collusion has poor patency uh around 50 to 65% below the knee in the tibial segments that patency dropped down even further. Uh I quote almost that one third of the patients with the tibial interventions with balloon angioplasty alone have recurrence uh uh within three months in those segments. So the patency is quite poor. We are no longer plumbers. We are, we use a lot of drugs now to deliver uh and deliver it into the vessel wall to prevent re stenosis. Uh paclitaxel balloons um have different excipients through which they are delivered through the inter media uh to prevent uh inter hyperplasia, which is the primary mechanism of failure for balloon angioplasty alone. So, after the balloon is inflated, there is vessel trauma and the vessel tries to have uh a lot of in growth in these segments. So, Pac Axol or Croy uh works on these segments and prevents re stenosis of these segments. It is lipophilic and it's rapidly absorbed while we're ballooning. Um um and we keep these balloons up for about three minutes. Um And that's how they prevent uh tima hyperplasia. They're able to have sustained drug levels in the media despite having a short contact of only about 2 to 3 minutes by uh having micro deposits uh in these vessels, long term patency uh at five year mark with impact Admiral Balloon, which is uh one of the best drug co balloons in the market at the moment is about 70%. Uh primary patency at five just compared to balloon, angioplasty, 45% at one year mark. The patency is about 87.5% which is honestly even better than some of the stent data that we have. Next up. We have plaque modification. Now, there's not a ton of literature around plaque modification, but there is some literature around plaque modification and ranges anywhere from Atherectomy which means removing the plaque or modifying the plaque. This is an example of a Hawk device which shaves the plaque and packs it in this nose cone and you can remove it from these segments to say a rotational ectomy device that create, that has a bar at the end and just spins and churns all the calcium into micro into microscopic particles. And then creates a flow channel or something like a jet stream which has blades that come out and spin at about 40 50,000 R PM and then create a smooth channel across these segments. Lithotripsy has become extremely popular which has and has emitters that help break the calcium bonds in these vessels, thereby increasing their compliance and improving the vessel patency with any adjuncts that be used like stems or balloons. We have laser which essentially evaporates or just like completely pulverizes the plaque and creates flow channels. Um When whenever we use regular balloons, the expansion within the plaque is not uniform that can lead to multiple ribs and can lead to uh uh trauma to these vessels uh leading to dissection flaps. So sometimes we use cutting balloons that have a more directed uh tear in the in the media leading to more um uniform expansion of the vessel wall. Whenever we run into situations where we have flow limiting dissections where the vessel still does not open up with some of these other means, we are able to put stents in which are uh uh woven and which are either woven stents or bare metal stents with interlinks like this. We also have the option of using covered stents uh which are flexible and made of night and all and uh can expand uh and even fit in vessels which have a lot of uh um movement like plete, artery, et cetera, balloon mounted stents are stainless steel stents, they have more radial force, but if compressed from the outside, they will deform. So we only use them in non flexion areas like iliac arteries or inside the belly where there is not going to be any direct force on these stents. Primary patency of stents is all over the place. However, if you use a stent that is uh uniquely designed for ay with a high radial force like Sara, the tech, the the results of these stents is excellent, upwards of 80%. Similarly silver ptx stent, which is a drug luing stent along with all Lovia, they have uh they have great primary patency uh for short segment lesions overall. Uh long term. Though once we place a stent, there is internal hyperplasia that can develop in the stents and that is still the achilles heel uh for uh these interventions and rein interventions through stents can be difficult. So we try not to place a stent as best as possible. Some of the technology with drug IU has uh been available to us on Zil ptx stent and most recently, Alluvial stent that helps us deliver drug directly into the vessel wall through the stent that has been shown to have better patency compared to traditional stents. Long term, they also have a track record of better uh limb salvage. Uh long term in some unique circumstances, we have to use stent graft. So they are the equivalent of fop prosthetic bypass graft that we used to do anastomosis on the outside. But essentially, you're putting the PTFE on the inside, it's an inert material. So it causes no issues within the stent. But at the edge of the stent, uh it can cause significant significant internal hyperplasia leading to uh failure. Long term. Uh The overall patency for a von stent uh which is a self expanding stent that is covered with PTFE versus uh a prosthetic fem pop bypass above the knee uh has been shown to have almost identical patency. So for patients who just need a fem above knee pop bypass, a lot of times you can choose either one of them and those options would be adequate for special circumstances where traditionally, we have not placed any stents, we have options of uniquely designed stents now that can, that have good radial pores and are very flexible and have excellent crush resistance. So, one of those examples is uh a supera stent which has a primary patency of about 89% even when placed in the public artery. Um some of uh these stents uh have evolved to a helical design now. So there is another helical stent now available that can also go into the public artery with excellent results if we run into a situation where we have no further options, all of their pedal vessels are occluded, proximal tubules are occluded. We have now over the options for deep venous arterial traditionally, we used to do this in an open fashion where we would perform greater sinus vein, anastomosis to the pal artery and then run valve at homes down the sinus vein to help arterialized the penis segment. This was not quite as effective. Uh We have done more in terms of surgical D VA by doing more targeted deep penis arterial organization by doing pedal de branching. Um But now we have an off the shelf uh device available that helps us achieve the same goals in an endovascular fashion called lymph flow. It's now it initially, it used to be available only as a part of trial. But lately, we have been able to access the device uh completely off the shelf. Now, in this uh technology, we cross from a proximal tibial vessel, say a poster tibial artery into the tibial vein and place a stent graft from the tibial artery all the way down to the level of the malleolus in the poster tibial vein and then use an anti grade valve atone that's proprietary by this company to open up the valves inside the foot and arterial lies the veins in the foot. So even if the arteries are not patent over time, what happens is that there is arterial organization of these venus circuits. And uh if somebody has tissue loss that can be healed with toe amputations or ATM a, a lot of times we are able to have uh limb salvage uh with these patients, even if these circuits go down in 3 to 6 months. Um This is an example of a 72 year old male with a history of significant peripheral vascular disease, right sided BK who had multiple uh 4 ft ulcers, including large planter, foot gangrene. Um And this is what the foot looked like a month prior to referral. This is how it looked uh within a month. So it progressed really rapidly. By the time the patient uh was evaluated, uh the A B I obviously shows significant uh reduction on the left side uh with a low toe pressure pre intervention. Uh baseline angiogram showed that the pty artery is open. Anterior tullar should be right here. It's completely occluded. This is the TP trunk, posterior teler and peroneal artery are severely diseased and posterior til artery is the only vessel that actually goes into the foot. We were able to get through this posterior tibial artery and we're able to perform excisional atherectomy of the poster tibial artery followed by balloon angioplasty with complete uh recanalization of this poster TPI artery with good filling of the foot. Uh We partnered with plastic surgery again in this case and uh we excised the plantar foot wound and plastic surgery, performed a free radium, uh free radial forearm flap to the left foot and ANAs the most to the post til art that we had recanalized. They also did the neuro the free flap to restore plantar sensation to see if that helped. And also the terminal arterial organization of the distal Sains branches in the forefoot. Since we did not have an A T, we also wanted something going to the forefoot for arterial organization to help uh heal uh that forefoot segment. Long term, six months later, the patient's index wounds had healed, but they developed a new pressure sore uh uh at a different site. So we repeated an angiogram at that point in time and that showed persistent uh small segment stenosis of this poster TBI artery right here that I'm trying to show you. So we, at this point in time, we placed a drug eluting coronary stent at this level which completely resolved the stenosis. And you can see on the angiogram there is excellent 4 ft filling uh all the way into the terminal branches here. Um At this point in time, there is one more stent that is available that is brand new. It's called an ere stent. It is the first of its kind drug luing bioabsorbable scaffold. So we put the stent in and over a course of uh two years, it's completely dissolved. Uh and it has been shown to have excellent patency uh in these uh difficult patient population. Subsequently, this patient came back and all his wounds had healed and he was discharged from uh wound care. A lot of times as vascular surgeons, we are faced with uh really uh tough situations like this. This patient had an isolated uh fourth toe gangrene, had a right p artery occlusion, but initially noted to have three vessels run off. And he was treated at an outside hospital with ar and at the time of Arar, all the pibil got embolized. Um and all the outflow was shut down and this is instead of just having a proto gangrene. Now, the patient presented the complete foot uh ischemia. So this was uh these are his baseline angiograms. Uh When we started the case, we are antegrade. So we're going straight down the common femoral artery, looking down the superficial femoral artery that they had reanalyzed initially and emboli down had completely occluded again. Uh It was heavily calcified and in terms of run off, you can see that all three tibial are now included. Anterior tibial artery is included at the top. We barely see any flow going through the peroneal artery and the posterior tibial artery and nothing is filling the foot because everything is showered and bleed. So what was done? Well, we did a lot of things but essentially it started with connecting the dots. So we started by reanalyzing this uh S fa and public lottery segment, which was quite challenging because of heavy calcium plaque did atherectomy at this segment and realigned this with a stent, we were then able to stick the foot and come up the anterior tibial artery to reanalyze this occluded anterior til segment and placed a coronary stent at this level, which could now be done with that babs orb scaffold. I suppose we recanalized this posterior tibial artery and removed all of the plaque debris that had gone into the posterior tibial arty. And we were able to clear all of this out with the exception of this tiny little chunk that remains. But since we were able to open up the anterior til and poster til up to the level of the ankle, we found that the arch was complete and he was still able to heal his T MA as a result of that. Every now and then we come across situations where we are evaluating a patient with toe gangrene, anticipating simple things like CLT I with multilevel disease as we have looked through so far in the talk. But we should also be thinking about other uncommon causes that could lead to a presentation like this, which are aneurysms leading to thrombo bols. And if we are not able to recognize these early, they can oftentimes result in major limb loss. This was one of my patients who presented with that toe toe gangrenes and essentially on duplex and on CT, they were found to have uh common fem artery aneurysm, which was filled with this mural thrombus. And essentially it was a and they were just showering this clot down into their leg leading to a toe gangrene. So the treatment was quite simple, we resected this aneurysmal segment and replaced it with an eight millimeter dacron graft that resolved the issue and they were able to heal their toe amputations. So in all of these circumstances, we have to uh be mindful that we are treating a patient and not just the lesion. So we have to be very flexible in our approach and try to come up with simple innovative solutions for these very complex problems and having a team approach uh is very, very important in taking care of these complex cot I patients. This is uh e even though we have talked about common from a lottery and I correct me having a 90% patency rate. That may not be the right answer for all for some of these patients. This is a lady with metastatic lung cancer, nonhealing, toe wounds and breast pain, um who had come from a lottery occlusion that I treated with enterectomy and excised the plaque and the vascular and then used a drug coated balloon to give her patency and she remained pain free for the remaining 3 to 6 months of her life before she passed away without having to have an inpatient admission and you know, a surgical incision. And this procedure took about 90 minutes to resolve all her issues so she could get on and have a meaningful quality of life for the remainder of her time. This is the 80 year old patient who had six previous open reconstructions with extensive wounds or calf with occluded, external iliac artery, uh occluded, common femoral artery, occluded. S fa that comes back to the P artery and the rest of the segment was opened. So instead of treating them with straight and or straight open techniques, again, I decided to do something hybrid because open alone would have been quite challenging and difficult and endo alone would not be durable. So this person got a hybrid intervention where we reconstructed the occluded, common formal artery, retrograde stented, the external iliac arteries and common iliac arteries on both sides, reanalyzed the S fa that was occluded, endovascularly and put a stent in and then re anastomose the S fa back onto the common femoral artery to give them patency. So it was a lot of work, but uh it was still done through a small uh 67 centimeter incision in the right groin rather than having to do a big belly operation and then doing multiple bypasses or just doing something straight in the vascular with more vacancy for multilevel disease like this. This is an 82 year old female who had breast pain and pre gangrenous changes. And this is the para visceral aorta. All of this calcium that we are able to see is heavy calci black in her juxta visceral aorta uh with near complete occlusion of her AOTA. She had a previously placed left green lottery stent that is occluded. Her right green lottery is completely gone and uh she was treated with bilateral radio artery axis. Bilateral comment from the lottery access through which we were able to drill through all of this plaque, recanalize her renal arteries, including the previously included renal artery stent, resent them. And then I was able to create a channel through the occluded infrarenal iota and use that shock wave lithotripsy balloon that we talked about that modifies the calcium bonds in the plaque and lets it expand more and give her a patency. So now, coming back to that bmif 60 with non healing, right, great toe with external occlusion, s fa pop occlusion and deep groin. So what are our options? Obviously, we can consider a big open bypass for them. Um But a bmif 60 somebody who has a lot of comorbidities that may not be the right person even though we are able to offer them uh something uh open. So, in that case, uh I considered an endovascular approach, this is a recap of their angiogram. The hypogastric is open, but the external iliac artery over here is completely occluded. Common femoral artery comes back with profunda outflow, but the superficial femoral artery that should live right here is completely gone and the artery opens back up at the level of the knee with the public artery being open. So in this case, I treated her with a simple six French sheet axis in the radial artery and a six French sheet axis in the foot uh because remember her groins were about 16 centimeters deep and we were able to reanalyze the external iliac artery from above. And we're able to put stent in the external iliac arty to recanalize that segment. We were then able to reanalyze the superficial cam artery from above and place the stent from the pedal approach because we did not have the right kind of stance that could reach those segments from the top. And then stinted her from the pedal approach from the S fa origin down to the public lottery with axial patency and then complete then resolution of her active issues. So in essence, uh please call, often call early uh because CLT I patients require very timely uh interventions uh for, for their complex issues. And we would love to partner with all of you to help uh with these difficult patients. Thank you. Thank you. OK. So we do have a question. Um Thank you for this review of Lymus and pad when ordering lower extremity arterial studies and outpatient settings for evaluating these patients. Do you order both formal A B I along with arterial duplex studies? Yes. Uh So Doctor Moore, I do uh order both A B I and RT L duplex for these patients because as I showed you in multiple scenarios, a lot of these patients, even if the A B I is normal or appears to be normal, uh they can hide a lot of disease, you know, in their RT O segments that can be further evaluated by a duplex. So essentially in a duplex, they're taking an ultrasound through every inch of their femoral artery, you know, or their public artery and to build vessels and trying to find these areas of occlusions. Sometimes A B I is misleading. Like we discussed in ESRD patients or diabetic patients where the vessels are calcified where they're artificially elevated. So in patients with wounds, I always get a duplex because even though getting ac T angiogram is not feasible in all of them because it's costly, it's kind of invasive. But a duplex is a very simple tool to conclusively evaluate their circulation. Um Just a comment from Doctor White. Awesome. Um and then just others. Thank you for all the lectures. A lot of great learning points if you all do have questions and you're just not thinking of now and they come up down the road. Um You can always email me or as I said in the follow up email, I'll have Doctor Cutter Paul's email address and then you can always email him and ask him down the road. Um So let me check and make sure I got everything everybody answered. It looks like I did. So thank you so very much. I appreciate it and then everybody thank you for attending. Um I will send out the follow up email. It will actually have the save the dates for the next sessions for next year and spring. Um, as well as look out for the CME credits within the week. Thank you so much, everybody. Bye. Enjoy your, enjoy your evening. Thanks. Created by Presenters Vipul Khetarpaul, MD Vascular Surgery View full profile
