Moderate to Severe Bilateral Claudication

Physician Name: R. Stefan Kiesz, MD
Northeast Methodist Hospital
San Antonio, TX

Relevant history and physical exam: This 69-year-old female diabetic presented with large, nonhealing gangrenous ulcers on both great toes (left more than right) and moderate to severe bilateral claudication. Elsewhere, she had recently undergone stenting of the right superficial femoral artery (SFA), with a suboptimal result. She was hospitalized on January 30, 2004 for abdominal discomfort and fever at which time she underwent amputation of both great toes. Dorsal pedis pulses were not palpable.

Besides her diabetes and severe peripheral vascular disease, this patient is dyslipidemic and hypertensive. She has severe coronary artery disease for which she has undergone previous CABG and PCI, and is on hemodialysis for end-stage renal disease.

Because this patient was still at significant risk for limb loss, we decided to attempt a rescue via SilverHawk plaque excision of both lower extremities.

Relevant catheterization findings: Diagnostic angiography on 2/12/04 showed two areas of significant, 80 to 90% stenosis in the left SFA and a 99% stenosed popliteal artery (Image 1). The posterior tibial artery (PTA) was completely occluded; the major vessel was the left anterior tibial artery (ATA) and it had a 99% ostial stenosis with a 60% proximal stenosis (Image 2). Distally in the area of the dorsal pedis there was an 80 to 90% stenosis. The left peroneal artery was almost completely occluded, and there was sluggish run-off to the foot.

Interventional management: Using a contralateral approach, a .0014" guidewire was advanced and the tip was parked in the distal portion of the dorsalis pedis artery. Using a 7.5 French SilverHawk Plaque Excision Catheter, multiple passes along the left SFA were performed, reducing the residual stenosis to about 5%.

The device was then exchanged for a 6.5 French device which was then advanced to the popliteal where several more passes were performed, effectively eliminating the stenoses in that area (Image 3). The device was then used to debulk and recanalize the left anterior tibial (Image 4). The device was withdrawn and redirected to the peroneal artery where several more passes were made, reducing the 99% stenosis there to less than 5%. There was no evidence of dissection anywhere and normal flow was returned to the foot. A total of 151 mg of tissue were excised from the left leg (Image 4.5). The patient reported warming of the left foot while still in the cath lab.

The patient returned to the cath lab four days later for angiography and treatment of the other leg. Angiography showed a patent stent in the right SFA with a 60% stenosis immediately distal to the stent and a diffusely diseased distal segment down to the popliteal, which was about 80% stenosed (Image 5). There was two-vessel run-off to the foot. The right PTA was completely occluded and there were 90% stenoses in the proximal peroneal and proximal ATA (Image 6).

Using a contralateral approach, plaque excision was performed in the right leg. Multiple passes with the SilverHawk 7.5 French catheter along the SFA were accomplished, decreasing the stenoses to less than 5% (Image 7). A 6.5 French catheter was then used to recanalize the popliteal artery. A smaller, 5.5 French SilverHawk catheter was used in the peroneal, reducing a 90% stenosis to about 5%. The catheter was exchanged once again for a 6.5 French device which was used in the distal popliteal and ATA (Image 8). A total of 197 mg of tissue were excised from the right leg (Image 8.5).

Patient again reported warming of the foot after the procedure and had 2+ pedal pulses present.

At follow-up, the ulcers on both feet were completely healed. The patient is now fully ambulatory and says she walks about a mile and a half every day.

Comments: This very sick patient had few options other than staged amputation of both lower extremities, an event that would have likely hastened her death. Staged, bilateral SilverHawk plaque excision restored blood flow to both extremities. Because it is a percutaneous procedure, there was little risk in attempting the procedure, which ultimately proved successful, and allowed for a limited recovery time.