Non-healing ulcer with superficial femoral artery (SFA) disease
Challenge
- 72-year-old male with non-healing left foot ulceration (Rutherford 5) and leg edema
- Relevant patient history:
- Diabetes with peripheral neuropathy
- Congestive heart failure
- Prior interventions:
- February 2009 - Left femoral to below-knee bypass with right saphenous vein (claudication)
- September 2010 - Vein bypass thrombosed, with unsuccessful attempt to treat the graft at outside institution. Developed non-healing ulcer on top of left foot. Calcified ankle-brachial indexes (ABIs), with toe pressure of 20 mmHg on left and 34 mmHg on right. No palpable pulses below left femoral level.
- October 2011 - Left SFA treatment
Image: Left SFA chronic total occlusion (CTO) with one-vessel runoff (not shown)
Images courtesy of Bruce Gray, MD. Used with permission.
Procedure
- Subintimal traversal without re-entry, followed by percutaneous transluminal angioplasty (PTA) and then re-entry using a CORDIS® OUTBACK® Device
- Deployed two 6 mm x 15 cm GORE® VIABAHN® Devices
Images courtesy of Bruce Gray, MD. Used with permission.
Result
- Maintained one-vessel runoff
- The patient went home after three hours with palpable dorsalis pedis pulse, ABI of 1.0
- Long-term anticoagulation / antiplatelet regimen: Warfarin and ASPIRIN (acetylsalicylic acid) Surveillance with duplex ultrasound within one month then at six months
- No recurrence of ulceration or need for other interventions and no amputations
- The patient died 11 months later (in September 2012) of respiratory failure associated with his congestive heart failure
Image: Post-placement of two 6 mm x 15 cm GORE® VIABAHN® devices. Maintained one-vessel runoff (not shown)
Images courtesy of Bruce Gray, MD. Used with permission.
Case takeaways
- Successful recanalization of SFA CTO in critical limb ischemia (CLI) patient
- Good inline flow through the SFA with preservation of tibial runoff
- Healing of ulcer and limb preservation in CLI patient
- Consider duplex ultrasound at frequent intervals through the first year, especially when runoff is limited
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