A 79-year-old man was referred for evaluation due to severe right calf pain on ambulation for 2 to 3 years and a recent nonhealing ulcer involving the dorsum of the foot with dry gangrene of the fifth toe.

His past medical history was significant for coronary artery ­disease with a myocardial infarction 15 years ago, which was ­managed medically without any further cardiac follow-up. He also suffered from chronic obstructive pulmonary disease (COPD), hypertension, and dyslipidemia and was a current smoker who smoked a pack a day with a 100-pack-year history.

His surgical history was significant for a carotid endarterectomy immediately prior to the myocardial infarction 15 years ago and a prior endovascular stent placed in the right lower extremity, about which details were not available.

PHYSICAL EXAMINATION

Relevant examination revealed a 75-year-old man who appeared older than his stated age. He was not in distress. His heart rate was 92 bpm, blood pressure was 149/82 mm Hg, and oxygen saturation was 90% on room air. He did not have carotid bruit. His cardiac examination revealed first and second heart sounds and a pansystolic murmur. Respiratory sounds were faint with mild expiratory wheeze bilaterally. Vascular examination was significant for pallor with dependent rubor in the right lower extremity but not the left. The left lower extremity had loss of hair and a 1-cm ulcer over the dorsal aspect of the lateral foot and dry gangrene of the fifth toe. Pulse was not manually palpable in the right femoral, popliteal, or pedal positions. A faint monophasic Doppler signal was recorded in the right popliteal and posterior tibial position, but not in the dorsalis pedis position. The left lower extremity had palpable pulses in the femoral and popliteal positions and biphasic Doppler signals in the dorsalis pedis and posterior tibial positions.

INVESTIGATIONS

Ankle-brachial indices were 0.4 on the right and 0.85 on the left, and segmental pressures and pulse volume recordings showed a significant decrement in right upper thigh pressure and pulse ­volume in comparison to the left, suggestive of right iliac stenosis or occlusions.

Electrocardiography showed anterior Q waves, with subsequent echocardiography revealing a left ventricular ejection fraction of 25% and moderate to severe mitral regurgitation.

Chest x-ray revealed hyperinflated lungs with a narrowed mediastinum and flattened hemidiaphragm. Pulmonary function tests were consistent with severe COPD.

Computed tomography (CT) angiography revealed a long-segment complete occlusion of the right common iliac, external iliac, and common femoral arteries (CFAs) with reconstitution in the right CFA. Faint right-to-left collaterals were noted from the left iliac arteries to the right CFA. The outflow was free of disease with 3-vessel run off below the knee (Figure 34-1).

MANAGEMENT

Several important factors need to be considered when deciding the best method of management for this patient.

1. 
   

   Life expectancy: A history of severe ischemic cardiomyopathy and severe COPD raises the question of this patient’s life expectancy and the appropriateness of undertaking a revascularization procedure. Considering he had severe but stable disease over the past 3 years without hospital admissions, one could expect the patient to live at least 1 year, during which time a loss of limb could result in reduced quality of life and increased morbidity and mortality.

   
   
2. 
   

   Medical therapy and supportive therapy versus ­revascularization: In the setting of critical limb ischemia due to a complete occlusion of the common and external iliac arteries, currently available medical therapy would not improve tissue perfusion to an extent to restore circulation. Smoking cessation would be an important aspect of his management. However, revascularization is the cornerstone of limb salvage in this patient.

   
   
3. 
   

   Best approach to limb salvage: Endovascular intervention ­versus open surgery with cross-femoral bypass grafting, aortofemoral bypass grafting, or axillofemoral bypass grafting would be the common invasive treatment options.

When considering patients for endovascular treatment of aortoiliac disease, the 2007 Trans-Atlantic Inter-Society Consensus (TASC) II document provides a classification of aortoiliac disease to guide therapeutic decisions (Figure 34-2).¹ Class A lesions are classified as the simplest lesions, with a high success rate with ­endovascular interventions. Class B and C lesions are progressively more complex but acceptable for endovascular intervention, whereas surgical repair is the preferred method for class D lesions.

According to the TASC II guidelines, our patient has a class D lesion for which recommended treatment is bypass surgery.

Of note, the TASC II guideline was published almost a decade ago, and since that time, advances have been made in devices, technique, and experience in endovascular aortoiliac intervention, with catheter-based therapies used more commonly in treatment of complex aortoiliac disease. Although these guidelines help identify the complexity of the lesion, they do not consider the patient’s candidacy for an operative procedure, which in our patient’s case carries a high cardiac risk.

As a result of advanced cardiac, pulmonary, and vascular disease and critical limb ischemia, management of this patient was complex and required precise discussion among the multidisciplinary limb preservation team at our institution, which included interventional cardiology, interventional radiology, podiatry, and vascular surgery.

Advantages of Endovascular Treatment Over Surgical Repair in This Patient

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  Use of local anesthesia eliminates complications related to general anesthesia.

  
  
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  Cardiac morbidity and mortality are extremely low with endovascular therapies in comparison to open surgical repair.

  
  
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  There are reduced transfusion rates with endovascular treatment.

  
  
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  Patient ambulates the same day or next day, which is important with baseline cardiac and pulmonary disease.

Despite these advantages, the most important consideration involves the success and patency rates after endovascular revascularization in aortoiliac disease involving class D lesions (Table 34-1).^2-10

Examining the data in Table 34-1, it can be seen that iliac stent placement has a greater than 95% success rate and primary patency rates of approximately 90% and 85% at 1 and 3 years, respectively.

The patient was deemed high risk for surgical treatment after multidisciplinary evaluation, and endovascular treatment was presented as the more reasonable method due to severe comorbidities.

Procedure Performed

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  Arterial access was obtained in the left CFA with placement of a 6-Fr sheath for aortic angiography and runoff.

  
  
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  The distal aorta and left common iliac and external iliac arteries were free of disease.

  
  
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  The right CFA was flush occluded and reconstituted at the CFA, which was significantly diseased and calcified. The right SFA was free of disease (Figure 34-3).

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  Ultrasound-guided access was obtained in the proximal right SFA by micropuncture technique; a 6-Fr, 7-cm short sheath was placed in the right SFA (Figure 34-4).

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  The lesion was crossed in retrograde fashion with a Fielder FC wire (Asahi Intecc, Aichi, Japan) and Corsair backup catheter (Asahi Intecc). A long stabilizer wire was advanced to the descending aorta from the right SFA sheath.

  
  
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  Intravascular ultrasound (IVUS) examination was undertaken due to a concern that the entry point to the aorta was not within the true lumen of the ostial common iliac artery and for measurement of vessel diameter.

  
  
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  True lumen entry was confirmed and common iliac artery diameter was measured to be 10 to 12 mm by IVUS exam with dense calcification.

  
  
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  Balloon angioplasty was performed in the common and external iliac arteries with a Vascutrak 6.0 × 80-mm balloon (Bard Peripheral Vascular, Tempe AZ) at 6 atm.

  
  
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  Due to heavy calcification, atherectomy with a CSI orbital atherectomy device (CSI, St. Paul, MN) with a 1.5-mm burr was used at 60,000 to 90,000 rpm.

  
  
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  Luminal gain secondary to atherectomy helped avoid stenting of the CFA.

  
  
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  Two Abbott Absolute self-expanding stents (Abbott, Chicago, IL) were placed in the common iliac artery (10 × 80 mm) and external iliac artery (10 × 60 mm) and postdilated with a 9-mm balloon.

  
  
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  Angioplasty of the CFA was performed with a Lutonix 7 × 40-mm drug-coated balloon (Bard Peripheral Vascular) (Figure 34-5).

  
  
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  After the procedure, the right dorsalis pedis and posterior tibial pulses were palpable.

  
  
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  The patient underwent amputation of the fifth toe and vigorous treatment for the wound with debridement and antibiotics. The wound was completely healed at the 6-week follow-up visit.

Recent advances in transcatheter therapies have led to a shift in endovascular interventions for aortoiliac disease, even in the setting of complex lesions such as TASC II class C and D lesions. Patients with peripheral arterial disease suffer from multiple comorbidities, and up to 40% suffer from significant coronary artery disease. Of these patients, the subgroup suffering from aortoiliac occlusive disease suffers from substantial loss of quality of life due to claudication and critical limb ischemia.¹¹ Endovascular treatment options are a valuable alternative to high-risk open surgical procedures. However, the operators are encouraged to recognize the risks associated with aortoiliac interventions with attention to careful case selection, procedure planning, technical skill, and bailout strategies that demonstrate successful results.