Endovascular Intervention to Improve Arterial Blood Flow: A Case Study
D. H. is a frail 82-year-old woman with history of diabetes mellitus, high blood pressure, and a stroke leaving her with left-side weakness. She also has arterial disease in both legs. D.H. continues to live at home with help and has a limited ability to walk.
She developed an infection of the left forefoot, which was diagnosed as osteomyelitis. She received an amputation of her left second and third toes and was placed on IV antibiotics through a PICC line at an outside institution. AFter the amputation, her left foot wound dehisced and she developed a tunneling wound in the foot.
Her outside doctors offered her a distal bypass procedure in an effort to heal her wound. She sought consultation with the Denver Wound Healing Center for options in management. At the Denver Wound Healing Center, she was found to have low left forefoot TCPO2s, which boded poorly for chances of healing without improving blood supply to the foot.
In viewing the arteriogram, we identified severe stenoses in several areas of the superficial femoral and popliteal system, but there was a patent anterior tibial artery to the mid and distal calf.
The patient was offered an attempt at endovascular improvement of her blood flow. One benefit of this approach was that, if successful, it would avoid open surgery, and if unsuccessful, it would not burn any bridges for future intervention.
On July 28, 2004, through a right common femoral approach, the left superficial femoral artery and popliteal arteries were accessed, and a cryoplasty balloon procedure was performed in the popliteal artery at the level of the knee and in the superficial femoral artery at the level of the adductor canal.
Thereafter, she regained a palpable left dorsalis pedis pulse. An open metatarsal amputation of the second and third toes on her left foot was then performed. The patient was discharged home the next day with continuing antibiotic therapy.
On August 9, 2004, the patient had a wound in the Denver Wound Healing Center measuring 30 x 14 x 33 mm. At that time, a wound VAC was applied. Antibiotics were halted on August 9, and by August 30, 2004, the wound size had decreased by half. By November 8, the wound measured 4 x 5 mm with minimal undermining. On January 17, 2005, the wound was declared completely healed.
D.H. continues to have no pain in her foot and palpable dorsalis pedis pulse on the left side one year post endovascular repair of disease of the infrainguinal vessels. She has thus far successfully avoided open arterial surgery and her foot remains healed.
In patients at increased surgical risk, catheter intervention may improve blood flow to the extremity enough to heal arterial wounds.
Written by Stephen Annest, MD, FACS Vascular Surgeon