1. The Missing Bifurcation
Sasanka Jayasuriya MD, FACC
Faisal Hasan MD, FACC, FSCAI
Yale University, New Haven, CT

2. Case Presentation
75 yo male was referred for peripheral angiography with critical limb ischemia and Rutherford Class V claudication due to a non healing ulcer of the right lower limb for 2 months.
Past History :
Prior lower extremity stent – details not available
Myocardial infarction 15 years ago without angiography or non invasive evaluation, carotid end arterectomy, hypertension, dyslipidemia, 100 pack year smoking history , current smoker.
Relevant Examination :
Vitals : HR 82/min, BP 148/82mmHg, Sats 94% on RA
Right lower extremity : Pallor, dependent rubor, hair loss, 1 cm ulcer in dorsal aspect of right great toe. No gangrene. Absent femoral, pop, DP, PT pulse
Investigations :
ECG – Anterior Q waves. CBC, Renal function, Coag panel : normal

3. Diagnostic angiography Complete occlusion of
right common iliac artery at origin.
Minimal left to right collaterals

4. Retrograde angiography through R/SFA sheath.
Ultrasound guided access was obtained in the mid right SFA by micro puncture technique
6F sheath was placed in R/SFA
Retrograde angiography through R/SFA sheath.

5. A Stabilizer XS wire was advanced through the micro sheath to the descending aorta.
Concern was raised if the entry point to the distal aorta was not within true lumen.
IVUS examination was performed and intraluminal position was confirmed prior to dilatation.
CIA diameter was measured to be 10-12mm by IVUS exam with dense calcification.
Balloon angioplasty was performed in the CIA and EIA with a Vascutrak 6.0 X 80mm balloon at 6 atms

6. Angiography revealing channel formation following angioplasty
IVUS exam to confirm intra luminal position in CIA

7. Orbital atherectomy
Due to heavy calcification atherectomy with a CSI orbital atherectomy device with a 1.5burr was used at 60 – 90,000 rpm.
Atherectomy helped avoid stenting of CFA

8. Final result 2 Abbott Absolute Self expanding stents Placed
CIA : 10 X 80 mm
EIA : 10 X 60 mm
Post dilation
Rival 8.0 X 40 mm
balloon at 8 atms.
Angioplasty of SFA and CFA performed with Rival balloon
Following revascularization symptoms improved from Rutherford Class 5 to Class 1 and ulcer healed in 2 weeks.

9. Mortality associated with chronic CLI
Patients presenting with chronic CLI have a mortality 20% at 1 year and 60% at 5 years
High risk
population
Norgren L et al. Journal of Vascular Surgery. Volume 45, Issue 1, Supplement , Pages S5-S67, January 2007

10. Operative mortality and morbidity
Adverse events leading to increased mortality and morbidity occur in >30% of patient undergoing lower extremity revascularization for CLI
40% of patients with CLI suffer from clinically significant CAD
Peri operative MI 6%
MI is silent in up to 30%
MI is fatal in 50%
suffering infarction
Flu HC et al. Morbidity and Mortality caused by cardiac events after revascularization for critical limb ischemia. Ann Vasc Surg Sep-Oct;23(5):583-97
Mamode N, Scott RN, McLaughlin SC, McLellland A, Pollack JG. Perioperative myocardial infarction in peripheral vascular surgery. B M J 1996;312:

11. TASC II Recommendations
Inter-Society Consensus for the Management of Peripheral Arterial Disease s
Unilateral occlusion of CIA and EIA : TASC D lesion
Recommendation for TASC D lesions:
Surgery is recommended treatment of choice for TASC D lesions
(level of evidence C)
Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33 Suppl 1:S1–75.

12. Revisiting our patient
75 yo with chronic CLI and previous MI with anterior Q waves, current smoker with 100 pack year history and carotid disease.
Options
Endovascular treatment under conscious sedation
Surgical revascularization with aorto femoral by-pass with potential risks of induction of anesthesia, intubation, aortic cross clamp, hypovolemia, pain, hypothermia, reversal of anesthesia, surgical incision, bleeding, anemia and transfusion

13. Time to re-visit TASC II?
Our case illustrates the success of endovascular revascularization in a safe and effective manner in a Class D lesion with the use of
Re - entry device
Atherectomy
IVUS guidance and
Stent placement
The procedure has
low morbidity and mortality
lower cost and
reduced length of stay in comparison with open surgical revascularization.

14. Critical limb ischemia Multi disciplinary evaluation
Is this the missing bifurcation?
Critical limb ischemia
Multi disciplinary evaluation
Endovascular operators, Vascular surgeons, Anesthetist, Cardiologist, Podiatrist
High op
Risk
Low op
Risk
Surgical
or Endo
Endo

15. With the availability of new devices for use
is now the time to support more aggressive endovascular revascularization in patients at high risk of peri-procedure cardiac events following multi disciplinary evaluation?