Case 1 Day 1
Case No.1 ( please use evidence to support your answer when available)
A 65-year-old male with a history of diabetes, hypertension, and smoking presents with lifestyle-limiting claudication in the left lower extremity. His DUS reveals a chronic total occlusion (CTO) of the superficial femoral artery (SFA).
Q 1:What is the important factors to consider in this gentleman’s history and clinical examinations.
Q 2: What is your approach in management of this gentleman?
Q 3: Venous mapping didn’t find suitable veins to be used what are the options for intervention ?
A1 he- non modifiable factors as advancing age , male sex … modifiable factors of atherosclerosis as smoking , DM and long term control , HTN
A2 control of DM and HTN p, smoking cessation and lifestyle modification including supervised exercise program. Patient developed PAD and in need for statins to control plaque and decrease risk of plaque rupture with superimposed thrombosis, also antiplatelet as plavix. Use of pletal is advised as a vasodialator with antiplatelet activity
A 3 failure of conservative medical ttt and life style modification can indicate the need of intervention – endovascular techniques has been used to cross CTO as use of guide wires as commando and special crossing devices as trailblazer.
In history:
He has diabetes, should have a good glycemic control
control of hypertension
smoking cessation
(all these factors combined contribute to a significant peripheral arterial disease)
in clinical examination:
know the claudication distance for the patient
assess peripheral pulses
look for trophic skin changes or change in color
approach and management:
risk factor modification and lifestyle improvement with walking exercises
Best medical therapy
preoperative full labs preparation
CTA for lower limbs
options:
endovascular approach or using synthetic graft (PTFE) for bypass
1-onset of pain (acute sharp , gradual ) , duration , control and medication of DM and htn , duration and pack per day of smoking
examination ( chronic ischemia signs loss of hair shinny thin skin , small healed ulcer
2- Ridk factor modification ( control of dm , htn) , stop smoking for at least 2weeks
Lab including cbc , pt, inr , kft, kft, hba1c , rbs , lipid profile
Cta if kidney function within normal range then arrange for:
A-Endovascular:contra lateral femoral or transbrachia
B- open femoro-popliteal bypass by venous or synthetic graft
3-open (ptfe bypass graft) if endo contraleral or trans brachial approach with cto guidwire with sfa stenting
A1 in history
risk factors assessment like DM-HTN -smoking -hyperlipidemia
asess patient complain site -intensity rest pain or not
asess patient work and daily activity
ask about family history – drug history
any other comorbidites like cardiac
asessment
ll pulsation
CRT – temp
neurological examination and sensation
abdominal examination
ABI
A2- approach
investigation labs
CBC – kidney function before CTA – coagulation profile
lipid profile -esr-crp
blood glucose level
imaging
duplex-ABI
CTA
mangement
lifestyle modification like smoking cessation and control HTN and DM
antiplatlet and statin
as patient had tasc D so better bypass surgery with ipsilateral GSV
A3 other option
bypass using contrlateral GSV or synthetic graft
we may try endovascular option through antegrade and retrograde approach
1- Hx of smoking, Glycemic control, BP control any previous interventions, any neurologic disorders, walking distance and period of rest, antiischeamic measures, the onset the course and duration of the claudication, his MET score and daily activities
Exam : trophic changes of feet, scars of previos interventions, bilateral pulse levels, ABI
2 – Approach: smoking cessation prog, DM & BP control, KFTs, discussion of the case and possible interventions, offering him BMT and exercise program
3- if conservative measures failed to improve his complaint, possible interventions will be decided after the cta or mra deciding the state of inflow and outflow vessels, calcification load, tibial vessels condition:either fempop bypass with synthetic ringed graft if general and cardiovascular condition is suitable for surgery and reasonable outflow
or endovascular intervention with planning for tools suitable for contralateral fem access, retrograde access, cto wires, ballons, and stents, atherectomy and DCBs are an option
And tools for tibials intervention if needed
Q1:
History:
>> detailed history about the risk factors :
DM and HTN: Duration, control, and other complications.
Smoking: Duration, intensity, and previous trials to cessation.
>> Claudication itself:
i need to make sure it’s pure arterial claudication and no other causes, or mixed pathology as it affects my management
>> how it’s limiting:
occupation and daily activities.
>> CVD:
History of coronary artery disease, or any cardiac events.
>> previous management:
i will ask about compliance with antiplatelet agents, statins, and other relevant medications.
Clinical Examination:
>> general examination as in case of any patient especially chest and heart.
>> full vascular examination starting from the other limb checking distal pulse, and measuring ABI.
>> Neurological examination:
to exclude the possibility of neurological claudication.
Q2: Approach to management:
this patient has claudication, so i will go with conservative management :
>> Risk Factor Optimization:
Smoking cessation.
Tight glycemic control.
Blood pressure control.
Lipid management.
>> Medications :
best medical therapy with
Antiplatelets, vasodilators and statins
>> Supervised exercise program to improve collateral circulation.
Q3: Options for intervention if no suitable veins:
>> PTA with or without stenting
we may use Atherectomy device if needed:
>> Surgical Options:
> Use of synthetic grafts PTFE
> Hybrid Procedures:
open surgery with endarterectomy and endovascular intervention.
Q1: Important Factors to Consider
History:
Diabetes: Poorly controlled diabetes can accelerate atherosclerosis, increasing the risk of peripheral artery disease (PAD).
Hypertension: Uncontrolled hypertension also contributes to atherosclerosis and PAD.
Smoking: Smoking significantly increases the risk of PAD and amplifies its severity.
Claudication:
Onset (gradual or sudden)
Distance walked before pain onset
Location and character of pain
Rest pain (indicating more severe ischemia)
Risk factors for atherosclerotic disease (hyperlipidemia, family history)
Clinical Examination:
Pulses: Palpate femoral, popliteal, posterior tibial, and dorsalis pedis pulses to assess the extent of arterial obstruction.
Skin changes: Look for signs of tissue ischemia, such as pallor, hair loss, and skin ulcers.
Neurological examination: Assess for signs of peripheral neuropathy.
Abdominal examination: Auscultate for bruits over the abdominal aorta.
Q2: Management Approach
Risk Factor Modification:
Smoking cessation: Emphasize the importance of quitting smoking.
Blood pressure control: Optimize blood pressure management.
Blood sugar control: Maintain optimal glycemic control.
Lipid management: Consider statin therapy to lower cholesterol levels.
Exercise Therapy:
Supervised exercise program to improve walking distance and quality of life.
Medications:
Antiplatelet therapy: Aspirin or clopidogrel to reduce the risk of thrombosis.
Cilostazol: A phosphodiesterase inhibitor that can improve walking distance.
Revascularization:
Endovascular therapy: For CTOs, this may involve complex techniques like rotational atherectomy, orbital atherectomy, or laser atherectomy.
Surgical bypass: If endovascular therapy fails, surgical bypass may be considered.
Q3: Options if Venous Mapping is Unsuccessful
If suitable veins cannot be harvested for bypass, alternative options include:
Endovascular therapy: As mentioned above, this may involve complex techniques to cross the CTO.
In situ vein bypass: Using veins from the contralateral leg or the patient’s own saphenous vein, even if it has some disease.
Synthetic grafts: Using prosthetic grafts like polytetrafluoroethylene (PTFE) or Dacron.
Palliative care: If revascularization is not feasible, pain management and lifestyle modifications are crucial.
Q1: age, comorbidities and how all of them controlled, smoking and it’s duration and amount of packs per day, his medications and allergies especially contrast allergy,any previous general or vascular interventions then I would like to take detailed history of his presenting complain
Regarding his examination I would start general assessment for his vital data followed by local examination of both lower limbs to assess pulses ,ischemic changes ,tissue losses and scars from previous interventions
Q2:I would like to ask for laboratory investigations to assess his fitness together with his state of diabetic controll and echo ,ECG,renal function tests ,CBC,INR and regarding his life limiting claudication I would like CTA for planning my intervention during this time I would advise the pt to quit smoking and continue BMT
Q3: plan a: endovascular intervention using antegrade sub intimal approach with or without retrograde approach to obtain TLR
Pan b: using contralateral GSV for bypass
Plan c: synthetic grafts for bypass
Q1
About hx
age old
Analysis complain Claufication
Site (buttocks or thigh etc)
Improving and get worse
Pain type (dull or sharp)
Time
Chronic disease (HTN ake about controlling and drugs , DM ask about controlling and drugs)
Special habit (smoking)
If there is previous surgeries or hospital admesion
.
About examination pt totally in brief
ABCDE then
bilaterally ll examination
Feel pulse from proximal to distal
Calculate ABPI
CRT
Asses temp
Motor
Sensory
Skin changes
Any ulcers
….
Q2
Pt with life limitations that means medical tt is failed
So I will go for surgical intervention
So I will ask for labs
Cbc
Urea creat
And
echo
Venous mapping Bilateral for bypass
Need CTA for get a wide view of inflow and distal runoff
Go first by endo by ante grade /retrograde to bypass this long lesion
But don’t burn my open trial
So can do bypass by contralateral GSV or by synthetic graft
Q(1): I will ask about;
Present history:
Smoking (amount and duration), HTN (controlled or not, medication), D.M (medication)
Complain: onset, course, duration, precipitating factors
Examination:
Vital signs: BP, RR, Temp and pulse
Local: presence of shiny skin, hairloss, capillary refill time,
Pulsation of both CFAs, sensory and motor power
ABPI measurement
Q(2):
Management:
Investigations: ABPI measurement
Labs: CBC, PT, PTT, INR, Renal functions
CTA of abdominal aorta and both L.L arteries
Treatment: Life style modifications
best medical therapy: Antiplatelets, vasodilators, statins
In case of CLTI: intervention for revascularization:
Open : bypass
Endo: balloon dilation and maybe stenting.
Q(3):
Using contralateral GSV if its diameter is suitable or bypass using synthetic graft
Endovascular by balloon dilatation maybe done.
1. Risk factors:
Dm ,HTN, Smoker. (Controlled or not ,adherence to medication &severity of diseases)
Life style , Occupation should be considered.
Exclude other risk factors .
Rest pain ?
Examination :
Pulse examination, tissue loss.
2. Investigations:
Pre operative assessment (blood workup, kidney function tests , Cardiopulmonary assessment , ECHO.)
Imaging: Duplex US , CTA, MRI if needed.
According to length of ocloded segment of SFA, and general condition of patient and fitting for surgery.
Patient will be prepared for Angioplasty Vs Bypass .
3.senthetic graft , Angioplasty
Q1 History &examination
-Personal history :: smoking index detection , sibling , fatty meals
– past history : level of DM control , BP grades , previous stroke or IHD
– present history: onset of cludication pain , cource , cludication distance , resting time , orher associated complains
—examination
General : pulse ( regularity – volume )
….BP , RR
Local : pulse ipsi and contra at CFA , pop A
Wasting of ms
Hair loss
Presence of ulcer or trophic changes over foot
———————
Management::
1- life style modification ( stop smoking, control blood sugar, BP , regular walking ongoing increased distances )
2- best medical therapy ( anti plt – cilostazole – statin – naftidrofuryl)
For 3 wks
3- if failed previous steps intervention required
A- endovascular ballon dilitation and stenting
B- atherectomy device
C-open surgery by pass
——————-
Q3
Endovascular ballon dilitation and stent
Atherectomy device
By pass using ringed ptfe graft
Q1:the important factors to consider are all risk factors of atherosclerosis and hence PAD
his old age and diabetes and hypertension and smoking, i will ask also about other vascular beds history cardiac or any previous CVA and any back pain
i will ask about the type of the pain what increase and how to relieve the pain
and will examine his limbs for any ischemic changes or ulceration and assess the pulsations and his ABI
Q2:the patient now has a disabling claudication which means that he has failed best medical therapy i will offer him according to the long SFA lesion and TASC D recommendations a surgical bypass after venous mapping
Q3: if no suitable veins ipsilateral or contralateral or upper limb veins we can use PTFE synthetic graft
still option endovascular crossing the long SFA lesion with ballooning and stenting could be tried first without affecting the future bypass option
Thank you for your excellent answers.
Q3: Are you suggesting primary stenting? Is there any evidence that this will not affect future options ?
No i would prefer the rule of leave nothing metal behind
and sure except if strongly needed specially in a case like this with long lesion and expected to leave a lot of dissection after ballooning
if it will be difficult to cross the lesion and reentry i will not extend the subintimal plan to a patent segment that could be used as landing for my future graft
History of medications like anticoagulant
Surgeries specifically vascular
Family history of vascular disease
Social regarding smoking
Symptoms analysis of claudications pain and other vascular symptoms
Spine problems with sciatica
Signs like color change skin loss and ulcers gangrene atrophic ischemic skin changes loss of hair diabetic foot infection capillary refilling time skin color and temprature compared with the other limb
ABPI distal pulsations on both sides
ECG for any ischemic changes or arrhythmia AF
Labs as CBC platelets lipid profile KFT coagulation profile INR
IMAGING DUS for iliacs and lowelimbs hemodynamics mainly for distal tibials runoff along with venous mapping of both GSV
CTA for anatomical details regarding the inflow outflow and the lesion
ECHO for function and fitness
For this patient fem pop bypass vein graft regarding the lesion TASC D total SFA occlusion If the GSV was not suitable as a conduit go for the contralat limb GSV if not we can use a synthetic PTFE graft
Thank you for your excellent answers.
Would you consider any other options before synthetic grafts
A1.. I will ask about history of other medical conditions as cardiac history and also medication history also I will analyze the claudication complain . To differ between neurogenic ,venous and ischemic claudication .
I will ask about
Precipitating factors and releasing factors
During exam I will check for distal . pulses . I will do ABPI and I will do straight leg raising test to differ between pain of neurogenic origin and ischemic pain
A2.. since the complaint is claudication I will start with best medical therapy at first . Single anti-bletlet and high dose of statins with risk factors modifications as smoking cessation , good controle of HTN. and DM ., also supervised training programs
I will adopt medical treatment for 3 months and if still lifestyle limiting after that I will proceed for CTA and preparation for revascularization
A3…
If the plan is to bypass the CTO. I will use GSV OR LSV. Of the samp limb if not suitable I will search for the other limb veins .. and if ont suitable I will use synthetic graft.. other options are endo vascular trail of revascularization by atheretomy catheters
Thank you Dr. Mahmoud for your excellent answers.
what evidence do we have to go for bypass first?
Are there any other options to consider before synthetic grafts?
What do you think is more durable A prosthetic graft or endovascular intervention?
both endovascular and surgical treatment are class IIa / level B evidence. choosing between both depends on lesion characteristics if it is a long total occlusion I think bypass will be more durable than endovascular
i will consider endovascular options before prosthetic graft
i think endo vascular is more durable and more liable for reintervention
Q1:What is the important factors to consider in this gentleman’s history and clinical examinations.
Full history to exclude orher bed affection tia stroke cardiac affection
ABI assessment +other limb assessment especially presence of fem pulse
Lipid profile*kidney function CBC assessment
Q 2: What is your approach in management of this gentleman?
Risk factors modification
Medical management anti platelets+antidyslipidemic +physical exercise+vasodilator
If not improved after med ttt and PT is urgening for intervention and after fully councling+informed consent
Pt may be prepared for intervention
After CTA + venous napping assessment PT planned for surgery Vs PTA
Q 3: Venous mapping didn’t find suitable veins to be used what are the options for intervention ?
Endovascular management by ante and retrograde acsess+using different tools according to availability for CTO crossings
Thank you Dr. AbdelRaheem for your excellent answers.
What other risk factor modification can you offer in general?
What is the evidence for using Vasodilators?
Can you clarify your endovascular intervention escalation strategy?
Risk factors modification
DM
Ht dyslipidemia
Smoking
Control
Life style modification
Endovascular intervention
Crossing a chronic total occlusion (CTO) in the femoral artery is a complex endovascular intervention requiring specific strategies to achieve success.
The choice of strategy depends on lesion characteristics, operator experience, and available equipment
First Intraluminal Approach Use hydrophilic guidewires and support catheters
Second Subintimal Approach Advance a guidewire into the subintimal plane plus or minus Use re-entry device
Third Retrograde Approach When Failure of antegrade crossing or challenging lesion anatomy
Through Popliteal artery or tibial arteries
Fourth Hybrid Approach (Antegrade-Retrograde Strategy) Combine antegrade and retrograde approaches simultaneously
Fifth open surgery+ ends vascular by femoral endarterectomy
Regarding use of vasodilator IN pad ttt
clinical guidelines provide recommendations on the use of vasodilators for managing intermittent claudication in patients with peripheral artery disease (PAD).
1. Cilostazol
The American College of Cardiology (ACC) and the American Heart Association (AHA) include a Class I recommendation for cilostazol in the treatment of symptomatic claudication. This classification indicates strong evidence supporting its efficacy.
Clinical Evidence: Multiple trials have evaluated cilostazol’s utility for treating symptomatic PAD. A systematic Cochrane Review of 15 trials concluded that cilostazol increases exercise tolerance compared with placebo. Specifically, 100 mg taken twice daily improved the weighted mean walking distance by 31.41 meters.
2 Naftidrofuryl
Guideline Recommendation: The National Institute for Health and Care Excellence (NICE) in the United Kingdom recommends naftidrofuryl oxalate as an option for treating intermittent claudication in people with PAD, particularly when supervised exercise programs have not led to satisfactory improvement.
Clinical Evidence: Naftidrofuryl has been shown to improve pain-free walking distances in some studies, offering an alternative for patients who cannot tolerate or have contraindications to cilostazol.
At last clinical experience from expert IN Egypt show improvement in claudication distance and symptoms by use of cilostazol
History
Medical history AF HF IHD dyslipidemia
Medications like anticoagulant
Surgeries specifically vascular
Family history of vascular disease
Social regarding smoking
Examination
Symptoms analysis of claudications pain and other vascular symptoms
Spine problems with sciatica
Signs like color change skin loss and ulcers gangrene atrophic ischemic skin changes loss of hair diabetic foot infection capillary refilling time skin color and temprature compared with the other limb
ABPI distal pulsations on both sides
ECG for any ischemic changes or arrhythmia AF
Investigation
Labs as CBC platelets lipid profile KFT coagulation profile INR
IMAGING DUS for iliacs and lowelimbs hemodynamics mainly for distal tibials runoff along with venous mapping of both GSV
CTA for anatomical details regarding the inflow outflow and the lesion
ECHO for function and fitness
TTT
For this patient fem pop bypass vein graft regarding the lesion TASC D total SFA occlusion
If the GSV was not suitable as a conduit go for the contralat limb GSV if not we can use a synthetic PTFE graft
Thank you Dr. Reda for your excellent answers.
Do you routinely ask for a CTA in all your patients? Are there other imaging modality options ?
Are there any other options to consider before synthetic grafts?
Can you clarify your endovascular intervention escalation strategy?