Successful Endovascular Therapy with Immediate

Surgical Debridement in a Case of Critical Limb

Ischemia Complicated with Severely Infected Ulcer

Kansai Rosai Hospital Cardiovascular Center

Tatsuya Shiraki, Osamu Iida, Shin Okamoto, Daigo Kanamori,

Kiyonori Nanto, Takuma Iida, Syota Okuno, Masaaki Uematsu

59 year old maleChief Compliant

Lt. foot non-healing ulcer with infection

Present illness

He had a worsening lt. 1st digit ulcer for three months without seeking medical care. Ten days before admission, he went to his doctor because of a fever and was referred to our hospital due to necrotic foot with infection.

Risk factor

Diabetes mellitus

Past history

None

Physical examination

Height 173 cm BW 56 kg BMI 18.7 kg/m2

BP 110/58 mmHg HR 90 bpm

SpO2 99 % (Room air) BT 37.8 ℃

Chest

cardiac sound: no murmur

lung sound: clear

Abdomen: soft & flat, no tenderness

Lower extremity

Palpation；Common femoral artery +

Popliteal artery –

Reddish +, Fever +, Swelling +, Pain +

Laboratory examination Lower extremity examination data

Ankle brachial index

Lt. 0.61

Ultrasound flow pattern

Lt. CFA Ⅱ

POP Ⅳ

DPA Ⅳ

PTA -

Skin perfusion pressure

No measurment

WBC 10000 /mm3

RBC 314× 104 /mm3

Hb 10.5 g/dl

Plt 23.2× 104 /mm3

T.Bil 0.3 mg/dl

AST 49 U/l

ALT 44 U/l

Na 139 mmol/L

K 4.2 mmol/L

Cl 104 mmol/L

BUN 11.4 mg/dl

Cre 0.65 mg/dl

CRP 8.6 mg/dl

HbA1c 10.4 %

Blood data

Culture dataMRSA 4＋

Diagnosis and treatment strategy

Diagnosis

# Critical limb ischemia

# Infective ulcer

# Diabetis mellitus

Treatment strategy

•Endovascular therapy

•Antibiotic therapy

•Debridement

•Insulin therapy

Proximal SFA Distal SFA

Initial angiogram

SFA ostium

LAO 30° RAO 30°

0.035 knuckle wire technique

Sheath6Fr Ansel sheath

(Cook Medical) Backup

5Fr MP catheter(Goodman)

Wire0.035 J-tip wire

(Radifocus)

SFA

0.035 knuckle wire technique

SFA post EVT angiogram

SFA

StentS.M.A.R.T Control 8× 100 mm

(Johnson & Johnson)S.M.A.R.T Control 8× 100 mm

(Johnson & Johnson)S.M.A.R.T Control 8× 100 mm

(Johnson & Johnson)Balloon

ADMIRAL XTREME 6× 120 mm(Medtronic)

Endovascular therapy

Pre

Pre

Post

Post

Tibio-peroneal trunk100%⇒0%

4.0*40 mm SHIDEN

Dorsal pedis artery100%⇒25%

2.5*200 mm SHIDEN OTW

(Kaneka)

(Kaneka)

Final below the ankle angiogram

Pre EVT Post EVT

Debridement

POD 30POD 14 POD 60

Clinical course

Summary

• A patient was referred to us because of a severely infected ischemic wound.

• EVT was immediately conducted on admission day.

• After EVT, the infective ulcer wassubjected to debridement by a plastic surgeon in the intensive care unit.

• Additional amputation and skin transplantation were performed and limb salvage was achieved.

• Patient’s status is now ambulatory.

Discussion

-The predictor of amputation after EVT for CLI-

95% CI Hazard ratio P value

Rutherford 6 1.228-4.387 2.321 0.0095

DM 1.100-4.792 2.296 0.0269

CRP＞5 mg/dl 1.251-5.341 2.585 0.0103

Age＜60 1.427-5.294 2.749 0.0025

Iida O et al., Eur J Vasc Endovasc Surg. 2012 Jan 10.

Discussion

-Risk stratification the predictor of amputation after EVT-

Iida O et al., Eur J Vasc Endovasc Surg. 2012 Jan 10.

•Rutherford 6•DM•CRP＞5 mg/dl•Age＜60

Low 0Mod 1-2High 3-4

Conclusion

• This case illustrates successful endovascular therapy in a case of critical limb ischemia complicated with a severely infected ulcer.