Cath Lab Digest

An 87-year-old gentleman presented with critical limb ischemia of the left leg. He had been followed at the Wound Care Center and had a left big toe non-healing ulcer of several centimeters’ diameter. It was so painful that the patient literally stated he wanted to have his leg cut off.

He was examined and noted to have no measurable ankle brachial index (ABI) by non-invasive studies. His risk factors included diabetes mellitus, continued tobacco abuse and hyperlipidemia. An angiogram was performed, showing that the common iliac arteries were widely patent. The abdominal aorta had diffuse plaque but no significant obstruction. There was a left common iliac stenosis of approximately 20% and dense occlusive calcification of the distal superficial femoral artery (SFA) popliteal artery. At the patella, the vessel appeared to recanalize, but there was no runoff to the anterior tibial posterior tibial or perineal vessels, and all three vessels were 100% occluded.

A contralateral approach was used, and despite using not only the tip of a Glidewire (Terumo Medical Corp., Somerset, New Jersey), but the back end of the wire as well, we were unable to cross into the true lumen. We also attempted to cross the lesion with a Confianza and Whisper wires (Abbott Vascular, Abbott Park, Illinois), but abandoned this and used an antegrade approach from the left femoral artery. A 6 Fr sheath was placed, the Glide catheter (Terumo Medical) passed, and we entered the subintimal space and exchanged for a Platinum Plus wire (Boston Scientific Corp., Natick, Massachusetts). We were unable to enter the proximal portion of the total occlusion, but just distal to the patella, we were able to pass the Outback device (Cordis Corp., Warren, New Jersey) and enter the true lumen. To perform angioplasty in the popliteal territory, 2.5 and 3.0 balloons were selected, and an AngioScore (AngioScore, Inc., Fremont, California) 5 mm balloon was used finally at the popliteal.

At the end of the procedure, the patient had a patent distal SFA and popliteal artery, as well as patent anterior tibial, posterior tibial and perineal vessels. Since the area that was crossed was infrapopliteal, we did not deploy a stent, but at 2-week follow up, the ulcer was healing and the patient no longer was experiencing pain in the left leg.

This is a case where use of the Outback device even in the infrapatellar region for salvage of a limb was successful.

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Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI, is an internationally-recognized cardiologist, inventor, educator and author. A diplomate of the American Board of Cardiovascular Diseases and American Board of Interventional Cardiovascular Diseases, Dr. Heuser is one of the early pioneers of angioplasty and is considered one of America’s top cardiologists. Dr. Heuser is currently in practice at the Phoenix Heart Center/Physicians Group of Arizona. He is Chief of Cardiology and Chief of Cardiac Catheterization Laboratory at St. Luke’s Hospital and Medical Center, Phoenix, Arizona, and Clinical Professor of Medicine at the University of Arizona College of Medicine, as well as Director of the Interventional Fellowship Program at the University of Arizona College of Medicine, Phoenix Campus.

With 13 patents granted for different catheters, stents and other medical devices, Dr. Heuser has served as principal investigator to research the safety and/or effectiveness of more than 100 medical devices and 70 pharmaceutical products, and has participated in more than 150 research studies. He has authored over 400 articles, textbooks and medical manuscripts, and is frequently invited to international medical conferences to present the findings of research developed in Phoenix.

Dr. Heuser received his medical degree from the University of Wisconsin School of Medicine in Madison, Wisconsin, and completed his medicine internship and residency, as well as his cardiology fellowship, at The Johns Hopkins Hospital in Baltimore, Maryland.