Case Study: Chapter 15

Chapter 15: Critical Limb Ischemia

NITEN SINGH, MD; ZACHARY ARTHURS, MD

CASE STUDY:

A 74-year-old patient is referred with recurrent cellulitis and pain in her left leg and inability to palpate pulses in the foot. She is an active smoker and has recently undergone percutaneous coronary intervention, with placement of 2 bare metal stents, for angina symptoms that have resolved. She was ambulatory before her pain limited her, and she cannot perform her cardiac rehabilitation due to her leg pain. She has chronic kidney disease but is not on dialysis. She states that her pain has been worsening over the last several months, to the point she has to sleep with her leg in the dependent position. Her medications include aspirin, clopidogrel, metoprolol, and simvastatin.

On physical examination, she appears frail and has a normal 2+ femoral pulse on the right and Doppler signal present at her left femoral artery. She does not have palpable pulses below this level. Doppler signals are present at the pedal level, with biphasic signals in her dorsalis pedis and posterior tibial artery on the right and only a monophasic signal present at the dorsalis pedis artery on the left. Her left leg has 1+ edema and is erythematous to the level of the knee when placed in the dependent position as opposed to the right leg, which has no edema or erythematous changes. The erythema in the left leg resolves when placed in the elevated position.

The resting ankle-brachial index (ABI) on the right was 0.7, with biphasic waveforms throughout the lower extremity. On the left, the resting ABI was 0.3, with monophasic waveforms throughout the lower extremity.

Case Study: Chapter 15

* 1.) What is the most appropriate course of action at this point?
* 2.) A CTA is performed. Case Study Figure A shows the findings at the level of the aortic bifurcation. Subsequent findings on angio graphy are shown in Case Study Figures B, C,and D. In addition to encouraging her to quit smoking and treating her comorbid conditions, what is most appropriate course of action in this patient?

* 3.) The patient’s popliteal artery and common iliac lesions are treated using an endovascular approach (Case Study Figures A–G).

Her symptoms completely resolve. Two years later, she presents again after a right cerebral stroke, 6 months prior, has left her with a left hemiparesis. In addition, she had a recurrent MI that is not amenable to PCI and has developed a large left heel ulcer. She requires hemodialysis for end-stage renal disease. On physical examination, she is bedridden and cachetic. She does not move her left lower extremity and has a palpable left femoral pulse but no palpable pulses at the foot. Her heel ulcer extends proximally, with portions of the Achilles tendon exposed. Which of the following is the most appropriate?