Fellows Case #2:Keep Me in The Loop! - vivaphysicians.org

Fellows Case #2:Keep Me in The Loop! - vivaphysicians.org

Fellows Case #2: Keep Me in The Loop! A Case Series of Critical Limb Ischemia Treated With Isolated Pedal Loop Angioplasty Joseph DeMarco, DO Morristown Medical Center Morristown, New Jersey Joseph DeMarco, DO Introduction Below-the-ankle revascularization is of great importance in the contemporary treatment of critical limb ischemia (CLI) patients. To date, studies have focused on below-the-knee revascularization. Isolated below-the-ankle revascularization has not been independently studied. We will present a series of 14 cases between 2013-2015 from our institution in which below-the-ankle lesions were identified and treated using angioplasty without additional concurrent infrapopliteal or femoropopliteal intervention. Joseph DeMarco, DO Case Study Demographics A retrospective analysis of Rutherford Categories V/VI patients who underwent below-the-knee (BTK) angioplasty between 2013 and 2015 was performed. 203 total patients identified.

14 patients (7%) only required isolated below-the-ankle (BTA) intervention with percutaneous intraluminal angioplasty (PTA). n = 14, M:F 10:4 Average age (Range) = 60.6 years (30-89) Cardiovascular risk factors: 71% DM (n = 10) 79% HTN (n = 11) 29% CKD (n = 4) 14% Smoker (n = 2) Joseph DeMarco, DO Index Case 58-y/o male with PMH of insulin-dependent DM, hyperlipidemia, and CAD s/p coronary angioplasty six years ago presents initially with a slow healing ulcer between 4th and 5th toes. Patient denies rest pain or claudication at that time. 3 weeks later, patient returns with worsening pain, edema, and worsening ulceration. Joseph DeMarco, DO Pertinent Physical Exam Findings Femoral and popliteal pulses are palpable bilaterally. Strongly palpable dorsalis pedis and weakly palpable posterior tibial artery pulse. Worsening edema. Ulcer between the left fourth and fifth digits on the left foot is enlarging, with active foul smelling exudate. Transcutaneous Oxygen Perfusion

Marginal Dorsal foot perfusion 37mmHg at rest and 41mmHg when elevated Adequate Plantar perfusion >100mmHg Joseph DeMarco, DO Pre-Intervention Angiograms PT, DP, and peroneal patent. Lateral plantar artery small in caliber. Plantar pedal loop incomplete Joseph DeMarco, DO Intervention Posterior tibial, lateral plantar artery and plantar pedal loop cannulated with 2.6F microcatheter and 0.014 Glidewire Advantage (Terumo, Somerset, New Jersey USA). 2.5mm angioplasty performed. Joseph DeMarco, DO Post-Intervention Angiogram Markedly increased lumen and flow rate in the posterior tibial artery and lateral plantar artery. Restored patency of a complete plantar pedal loop. Post

Pre th th Enhanced wound blush to 4 /5 intertriginous region. Joseph DeMarco, DO 6 Week Clinical Follow Up Before After Joseph DeMarco, DO Pedal Loop Assessment Dorsal Pedal Circulation Plantar Pedal Circulation Manzi M et al. Vascular Imaging of the Foot: The First Step toward Endovascular Recanalization. Radiographics 2011; 31:1623-1636. Joseph DeMarco, DO Types of Interventions 1)

DP / dorsal loop alone (n= 2) 2) PT / plantar loop alone (n= 7) 3) Entire plantar pedal loop (n= 3) 4) Other (n= 2) Before Treatment After 1 2 3 Joseph DeMarco, DO n A G

E S E X Wound Angioplasty Location Angiographic Success Follow Up Clinical Healing 1 89 F 4th/5th intertriginous MP Y No follow up. Deceased.

Unknown 2 60 M Dorsal 1st & 3rd toes DP Y Amputated hallux and 3rd toe Pain improved Triphasic flow into foot Planned TMA Healing 3 66 M Plantar 1st & 2nd toe amputation site

LP Y No pain GI bleed on Plavix/ASA Healed 4 72 F Calcaneal LP N Triphasic flow, ABI 1.07 Healed 5 54 M

Calcaneal DP + LP Y Amputated hallux Calcaneal healed Healed 6 51 M Plantar Hallux DP + PP Y Amputated hallux Angiogram- Pedal loop intact Healed 7 60

F Plantar 3rd toe LP N I&D Unknown 8 54 M Dorsal Hallux MP + DL N US Duplex Triphasic flow to foot Healing 9 30

M Lateral 3rd-5th toe amputation site MT Y TcPO2 study sufficient perfusion Healing 10 71 M Calcaneal DP+PP+LP Y New SFA stenosis Triphasic flow to foot TcPO2 study insufficient perfusion Non-healing 11

58 M 4th/5th intertriginous LP+PP Y Healed, LE Duplex neg, ABI nml Healed 12 50 M Plantar 2ND toe LP N No pain Healing 13

56 M Distal 3rd toe amputation site DP+PP+LP Y No pain Healing 14 77 F Dorsal midfoot DP+PP+LP N TMA Non-healing TMA

KEY: MP-medial plantar; LP-lateral planter; DP-dorsalis pedis/dorsal loop; PP-plantar perforator (deep plantar); DL-deep loop; MT-metatarsal Joseph DeMarco, DO Results Technical Angiographic Success Defined as <50% residual stenosis 9/14 (64%) Clinical Follow Up (Mean 112.6 days, Range 0-265 days) Complete healing: n = 5 (36%) Partial healing: n = 5 (36%) Non-healing: n = 2 (14%) Amputation: n = 2 (14%), 1 planned pre-intervention No follow up: n = 2 (14%) Endovascular Reintervention: n = 1 (7%) Joseph DeMarco, DO Discussion Percutaneous transluminal angioplasty (PTA) has become first line management for patients with critical limb ischemia (CLI). Below-the-ankle angioplasty has been previously described as a potential adjunct treatment to proximal angioplasty. However, our study demonstrates that isolated below-the-ankle stenosis/occlusion can be a potential source of CLI. Therefore, three-vessel run off cannot be used as the sole

determinate of adequate perfusion for healing. Rather, it is important to identify: Anatomic variations in pedal arterial supply Pedal arch integrity Hallux and calcaneus as watershed regions Joseph DeMarco, DO Conclusions Below-the-ankle revascularization with PTA is technically feasible and associated with clinical improvement. Improvement in primary wound healing and post-amputation healing. Real-time angiographic analysis rather than the angiosome model should be used to assess below-the-ankle microvasculature and determine the revascularization target. An intact pedal arch has been associated with improved wound healing and higher patency rates. Close clinical follow up is necessary focusing on wound healing and pain improvement instead of repeat imaging. Follow up Doppler US is not necessary or accurate in evaluating healing caused by below-the-ankle lesions. The use of TcPO2 measurements may be helpful in determining adequate reperfusion to promote wound healing (Redlich et al). Joseph DeMarco, DO References

Abdelhamid MF, Davies RSM, Rai S, Hopkins JD et al. Below-the-ankle Angioplasty is a Feasible and Effective Intervention for Critical Leg Ischemia. Eur J Vasc Endovasc Surg 2010; 39:762-768. Biancari F, Alback A, Ihlberg L, et al. Angiographic runoff score as a predictor of outcome following femorocrural bypass surgery. Eur J Vasc Endovasc Surg 1999;17:480-485. Davies MG, Saad WE, Peden EK, et al. Impact of runoff on superficial femoral artery endoluminal interventions of rest pain and tissue loss. J Vasc Surg 2008;48:619-26. Fernandez N, McEnaney R, Marone LK, Rhee RY et al. Multilevel versus Isolated Endovascular Tibial Interventions for Critical Limb Ischemia. Journal of Vascular Surgery 2011; 54 (3):722-729. Katsanos K, Diamantopoulos A, Spiliopoulos S, Karnabatidis D and Siablis D. Below-the-ankle Angioplasty and Stenting for Limb Salvage: Anatomic Considerations and Long-term Outcomes. Cardiovasc Intervent Radiol 2013; 36:926-935. Kawarada O, Yokoi Y, Higashimori A, Waratani N et al. Assessment of Macro- and Microcirculation in Contemporary Critical Limb Ischemia. Catheterization and Cardiovascular Interventions 2011; 78:1051-1058. Lee AC and Khaddus MA. Pedal Arch Revascularization: The Rationale Behind this Procedure and Tips from Preprocedure Planning and Intervention. Endovascular Today May 2014; 77-82. Manzi M, Cester G, Palena LM, Alek J et al. Vascular Imaging of the Foot: The First Step toward Endovascular Recanalization. Radiographics 2011; 31:1623-1636. Misra S, Lookstein R, Rundback J, Hirsch A et al. Proceeding from the Society of Interventional Radiology Research Consensus Panel on Critical Limb Ischemia. JVIR 2013; 24:451-458. Rashid H, Slim H, Zayed H, Huang D et al. The Impact of Arterial Arch Quality and Angiosome Revascularization on

Foot Tissue Loss Healing and Infrapopliteal Bypass Outcome. Journal of Vascular Surgery May 2013; 57 (5):12191226. Redlich U, Xiong YY, Pech M, Tautenhahn J et al. Superiority of Transcutaneous Oxygen Tension Measurements in Predicting Limb Salvage After Below-the-Knee Angioplasty: A Prospective Trial in Diabetic Patients with Critical Limb Ischemia. Cardiovasc Intervent Radiol 2011; 34:271-279. Zhu YQ, Zhao JG, Liu F, Wang JB, Cheng YS et al. Subintimal Angioplasty for Below-the-Ankle Arterial Occlusions in Diabetic Patients with Chronic Critical Limb Ischemia. J Endovasc Ther 2009; 16:604-612. Joseph DeMarco, DO ENGAGE Watch. Interact. Navigate. [email protected] ATTEND VIVA 16 In September! September 18 - 22, 2016 Wynn Las Vegas

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