•A 69 years old female with long history of DFI with chronic ulcers of right foot and PVD in the past; presenting in the Diabetic Foot Clinic with recurrent ulcer of the Rt foot for the last 2 weeks with rest pain.
•PMHx DM-II, HTN, CVS, PVD Had Right CFA Endarterectomy 5 years ago
•Physical Examination Absent pedal pulses Rt forefoot tender to touch Large ulcer on the plantar aspect of the big toe
Diagnostic Angiogram :
•Vein mapping of LL Absence of suitable autologous vein on either side
•Questions: 1.Discuss your management plan with clarifying pros and cons.
11 Comments
Ahmed Bedeer
step 1 diagnosis
Clinically > RT L.L chronic limb threatening ischemia accompanied with RT DFI diangnostic angiogram > shows recurrent stenosis in SFA,CFA With fiant infra-popliteal arterial system that needs repair WIFI SCORE > (W:1/I:1/FI:1) which means low risk for amputation and high benefit of revascularizationStep 2 Urgent hospital admission.
IV fluids resuscitationLabs: CBC , Coagulation profile, Renal functions, electrolytes to evaluate sepsis conditionPlain X-ray of RT foot to exclude osteomyelitis or MRICT angio to evaluate inflow and vessel calcificationMRI to evaluate infragenicular vessel lumenDuplex US on arterial system including the patency and flow form in the arterial tree, prescence of atherosclerotic plaques and their respective percent stenosis of the associated vesselsmeasure ABI Empirical I.V antibiotics, antipyreticsUrgent drainage of abscessCulture and sensitivity tests and bone biopsyControl diabetesanaesthesia consultation fitnessstep 3 urgent revascularization:
Endovascular by contralateral ( cross over) approach from LT CFA to access the RT CIA then revascularization of RT EIA, CFA, SFA, Pop A, PTA and peroneal A + stenting of RT EIA.(((This is a good option to be avoid the RT groin wound and due to history of RT CFA endarterectomy, but may be difficult to access the RT infragenicular portion of RT Popliteal and crural vessels))).Endovascular by retrograde access through one of the crurals -preferably the ATA as it’s patent proximally Then passage of the wire with escalation . We may need vessel preparation with lithotrepsy or atherectomyHybrid by combining both RT CFA redo endarterectomy with venous patch closure and RT iliac artery angioplasty with stenting to restore the inflow, then distal angioplasty.Hybrid: CFA redo endoarterectomy and angioplasty of RT iliac vessels with stenting then Fempop infragenicualr bypass using synthetic PTFE graft.(((However the synthetic graft not recommended due to risk of infection from spesis))).step 4 medical care:
best anti-ischemic treatment should be considered using vasodilators, statins, anti-platelet and low dose aspirin according to compass trialEndocrinologist for control of DiabetesNutritionist for diet controlstep 5 Wound care :
surgical debridement up to big toe amputationdaily redressing with chemical and enzymatic debridement to make sure that the wound is clearhyperbaric O2VAC therapy.offloading therapy using RCBs ( as the big toe area is one the pressure points of the foot)Podiatrist for care of foot
The diangnostic angiogram shows recurrent stenosis in SFA,CFA With fiant infrpopliteal arterial system tht needs angioplasty propably..
Frist or all I will order CBC ( looking for leukocystosis)
Then Xray on the big toe AP and laterl views ( looking for osteomyelitis)
I will do culture and senstitvity from the wound for proper antibiotic choice
This patient is WIFI SCORE (W1I1FI 1)which means low risk for amputation
Starting the Antiobiotic empircal unitl Cand S appears
Then pateint will undergo transbrachial/crossover angioplasty of the external iliac ,CFA,SFA andtibials (Because of hostile groin for thr previous operation)
If failed retrograde angioplasty may be considered
After doing the angioplasty I will asses the pedal pulse and wavform by HHD
Then I will do surgical debridment and follow up for any recurrent infection
Then I will apply complete offloading ( as the big toe esp this area ulcerated is one the pressure points of the foot) ( By RCB)
with daily dressing and follow up for the wound
I may use the Vac for formation of granlation tissue
Hx taking : risk factors for DFI; diabetic control, HTN, comobidities of PAD as IHD and CVD
Examination : general if pt is toxic/ septic due to infection – BP and HR. Local Exam including distal pulses and if there is any collection in the foot, probe to bone testing in case of deep ulcer
Basic investigations: CBC- leucocytosis , S crt , wound culture and sensitivity, Duplex US on arterial system including the patency and flow form in the arterial tree, prescence of atherosclerotic plaques and their respective percent stenosis of the associated vessels
initial TTT include hospitilization with vitals monitoring, starting with antibiotic coverage and to be adjusted after C and S, IV fluids if not overloaded, Diabetic control and maintaining adequate Blood glucose control
assessment for the possibility of incision drainage of the foot if there is detectable collection within necrotic tissue
revascularization
proposed plan in endovascular in this case as pt has previous femoral exposure with subsequent adhesions
– cross over access for angioplasty of the proximal sfa (stenosis and long segment CTO)
if failed trial retrograde access through one of the crurals -preferably the ATA as it’s patent proximally
passage of the wire with escalation whether retrograde or antegrade
vessel preparation with lithotrepsy can help improve outcome
patient will propably require stenting given subintimal wire passage and the long segment lesion
A –
admission of patient
start sepsis 6 give patient o2 and antibiotics and fluids
withdraw full lab and lactate and blood culture -crp – lipid profile -HBA1c
measure ABI and duplex of ll and cta
our options
1 contralteral angioplsty
its advantage avoid open surgery especially in redo endarterectomy
give us a working distance
its cons less pushability and we may cant cross this long TCO in sfa
2 retrograde approach
it help us with crossing the lesion
but it may disrupt our only run off
3 hybrid technique through redo endartectomy
and proximal angio
and fem pop bypass using aynthetic graft or we may try distal angio
its cons it os a redo surgery so there is more risk of injury to fhe vessels and infection to wound
graft problems either infection or thrombosis
Hospitalization as a case of CTLI with DFI
Resuscitation with normal saline
Iv broad spectrum antibiotics
RBS detection and rapid control proceeded
Lap investigations ( cbc-crp-creat-Hba1c-lipid profile-creat)
Radiology x ray foor , ankle
——
Surgical intervention: evacuation of pocket of pus , mild debridement
Diabetologist consultation for glycemic control
Anathesologist consultation for surgical intervention
Pre op preparation ( good hydration – decline of sepsis markers – undercover of antibiotics- good urine out put )
Operation::
Plan A contralateral femoral access with iliac dilitation and cfa dilitaion then ipsilateral access by sheath 6 then sfa , pob, tibial angioplasty
Then ballon 5 inflation at cfa for 5 minutes post removal of sheath( mechanical closure of ostium)
——
Plan B
Rt femoral endarterectomy and retrograde iliac angioplasty then antegrade sfa ballon dilitation and pop angioplasty
——-
Plan c
Trans brachial access
Passing wire till tibials
Atherectomy device use at level of iliac, sfa, pop
——
Plan D
Open iliofemoral bypass
Fem- tibial bypass
——
Then big toe amputation
Pt with RT L.L chronic limb threatening ischemia accompanied with RT DFI.
needs:
-Urgent hospital admission.
-IV fluids resuscitation
-Labs: CBC , Coagulation profile, Renal functions, electrolytes
-Plain X-ray of RT foot to exclude osteomyelitis or MRI
-Empirical I.V antibiotics, antipyretics
-Urgent drainage of abscess
-Culture and sensitivity tests and bone biopsy
-Control diabetes
Then prepare patient fo urgent revascularization:
-Endovascular by contralateral approach from LT CFA to access the RT CIA then revascularization of RT EIA, CFA, SFA, Pop A, PTA and peroneal A + stenting of RT EIA.
This is a good option to be avoid the RT groin wound and due to history of RT CFA endarterectomy, but may be difficult to access the RT infragenicular portion of RT Popliteal and crural vessels.
-Hybrid by combining both RT CFA redo endarterectomy with venous patch closure and RT iliac artery angioplasty with stenting to restore the inflow, then distal angioplasty.
-Hybrid: CFA redo endoarterectomy and angioplasty of RT iliac vessels with stenting.
then Fempop infragenicualr bypass using synthetic PTFE graft.
However the synthetic graft not recommended due to risk of infection from spesis.
-Pharmacological medications: best medical treatment should be considered using vasodilators, statins, antiplatelets.
-Wound care : hyperbaric O2 or VAC therapy.
-Endocrinologist for control of Diabetes
-Podiatrist for care of foot
-Nutritionist for diet control
admission and resuscitation iv fluids and antibiotics and control of glycemic level
x-ray and assessment of the infection extent
arrange for drainage surgery to eradicate the septic focus
arrange for revascularization endovascular which gives us option to treat the multilevel disease we have in the angiography and given a history of previous femoral exploration
the endovascular option for CFA may compromise the profanda femoris ostium and may need stenting which is still not evidenced and needs more study to assess its efficacy
if failed hybrid can be done with femoral endarterctomy using bovine patch due to lack of suitable conduit and EIA angioplasty and femoro-Pop(P3) bypass in this option too much steps if you need to full reavscularize the foot in such extensive wound
A case of RT L.L chronic limb threatening ischemia accompanied with RT DFI.
She needs:
-Urgent hospital admission.
-IV fluids resuscitation
-Labs: CBC , Coagulation profile, Renal functions, electrolytes
-Plain X-ray of RT foot to exclude osteomyelitis
-Empirical I.V antibiotics, antipyretics
-Urgent drainage of abscess
-Culture and sensitivity tests
-Control diabetes
Then prepare patient fo urgent revascularization:
-Endovascular by contralateral approach from LT CFA to access the RT CIA then revascularization of RT EIA, CFA, SFA, Pop A, PTA and peroneal A + stenting of RT EIA.
This is a good option to be avoid the RT groin wound and due to history of RT CFA endarterectomy, but may be difficult to access the RT infragenicular portion of RT Popliteal and crural vessels.
-Hybrid by combining both RT CFA redo endarterectomy with patch closure and RT iliac artery angioplasty with stenting to restore the inflow, then distal angioplasty.
-Hybrid: CFA redo endoarterectomy and angioplasty of RT iliac vessels with stenting.
then Fempop infragenicualr bypass using synthetic PTFE graft.
However the synthetic graft not recommended due to risk of infection from spesis.
-Pharmacological medications: best medical treatment should be considered using vasodilators, statins, antiplatelets.
-Wound care : hyperbaric O2 or VAC therapy.
-Endocrinologist for control of Diabetes
-Podiatrist for care of foot
-Nutritionist for diet control
Patient in this case has critical limb ischemia associated with diabetic foot infected ulcer so she needs urgent admission and multi-disciplinary management by internal medicine for DM control, also cardiology to control codex cardiac and hypertension
Investigations full lab including CBC, serum creatinin, serum urea CRP alt AST and INR, culture and sensitivity
X rat foot post ant and lat veiws: to exclude osteomyelitis and gas formation if yes we may proceed to amputation
Regarding vascular intervention the patient had iliac stenosis common femoral artery stenosis and flush lesion sfa till the P3 Segment with continued anterior tibial artery only as the distal run off
I prefer to start endo-vascular approach via left brachial access, traversing the CIA, CFA, SFA, till the tibials
It is a challenge, if difficult, we can try hybrid approach (CFA ENDARTRECTOMY+ retrograde iliac angioplasty, SFA and trial of tibial angioplasty)
if failed, fem-pop 3 bypass is the option in the same session.
foot debridement will be done according to level of infection Just Post-operatively
69 year old lady presented with rt CLTI she had prior history of revascularization . And now presented with foot ulcer with signs of infection in the form of redness and tenderness .. management will start by patient admission and starting emberical antibiotic treatment while labs are obtained . CBC ,KFT, LFT, CRP, ECG, and foot X-ray
then anaesthesia consultation for patient fitness for surgery
This patient has and angiography showing multilevel vascular lesion EIA, CFA, SFA with single run off ATA
I THINK hypried approach here is so good with redo CFA endarterectomy and patch-plasty
Then iliac angioplasty and stenting
With long bypass from CFA to ATA by synthetic graft
It is a long and exhausting operation but
For this multi level disease and long SFA occlusion it is a reasonable option to get long straight blood flow line to the foot
However the long term patency og synthetic graft is questionable and not as durable as native graft
So post operative graft surveillance and life long antipletlets and low dose revaroxiban is advised
Post revascularization wound depridement is required together with proper wound offloading and dressing
Admission
Resuscitation iv antibiotics and fluids
Labs cbc crp for sepsis
Imaging xray for deep infection gas FB OM
Endocrinologist and nutritionist for diabetes control
Anesthesiologist for fitness
Evaluation of his neurological condition regarding the ulcer mixed cause
Prepare for urgent drainage and debridement together with c/s with big toe amputation to be considered along with revascularization
Revascularization options
1: endovascular because of multiple levels lesions and previous groin wound full correction angioplasty of EIA CFA SFA POP PTA PERONEAL
2: hybrid redo CFA EA then closure with vein or bovine patch for infection and continue angioplasty retrograde for iliac and distal for sfa pop and tibials with difficulty regarding angioplasty of the pop behind the knee
3: hybrid EA of Cfa angioplasty of the EIA and fem pop BTK bypass graft synthetic to P3 with cuff which is not the best option due to infected foot after angioplasty of the tibials to secure distal run off for graft patency
These options done in parallel with the BMT, antibiotics according to culture by microbiologist for ttt of infection, offloading by orthotist, podiatrist for wound care management and dressings, physiotherapy for rehabs
step 1 diagnosis
Clinically > RT L.L chronic limb threatening ischemia accompanied with RT DFI diangnostic angiogram > shows recurrent stenosis in SFA,CFA With fiant infra-popliteal arterial system that needs repair WIFI SCORE > (W:1/I:1/FI:1) which means low risk for amputation and high benefit of revascularizationStep 2 Urgent hospital admission.
IV fluids resuscitationLabs: CBC , Coagulation profile, Renal functions, electrolytes to evaluate sepsis conditionPlain X-ray of RT foot to exclude osteomyelitis or MRICT angio to evaluate inflow and vessel calcificationMRI to evaluate infragenicular vessel lumenDuplex US on arterial system including the patency and flow form in the arterial tree, prescence of atherosclerotic plaques and their respective percent stenosis of the associated vesselsmeasure ABI Empirical I.V antibiotics, antipyreticsUrgent drainage of abscessCulture and sensitivity tests and bone biopsyControl diabetesanaesthesia consultation fitnessstep 3 urgent revascularization:
Endovascular by contralateral ( cross over) approach from LT CFA to access the RT CIA then revascularization of RT EIA, CFA, SFA, Pop A, PTA and peroneal A + stenting of RT EIA.(((This is a good option to be avoid the RT groin wound and due to history of RT CFA endarterectomy, but may be difficult to access the RT infragenicular portion of RT Popliteal and crural vessels))).Endovascular by retrograde access through one of the crurals -preferably the ATA as it’s patent proximally Then passage of the wire with escalation . We may need vessel preparation with lithotrepsy or atherectomyHybrid by combining both RT CFA redo endarterectomy with venous patch closure and RT iliac artery angioplasty with stenting to restore the inflow, then distal angioplasty.Hybrid: CFA redo endoarterectomy and angioplasty of RT iliac vessels with stenting then Fempop infragenicualr bypass using synthetic PTFE graft.(((However the synthetic graft not recommended due to risk of infection from spesis))).step 4 medical care:
best anti-ischemic treatment should be considered using vasodilators, statins, anti-platelet and low dose aspirin according to compass trialEndocrinologist for control of DiabetesNutritionist for diet controlstep 5 Wound care :
surgical debridement up to big toe amputationdaily redressing with chemical and enzymatic debridement to make sure that the wound is clearhyperbaric O2VAC therapy.offloading therapy using RCBs ( as the big toe area is one the pressure points of the foot)Podiatrist for care of foot
The diangnostic angiogram shows recurrent stenosis in SFA,CFA With fiant infrpopliteal arterial system tht needs angioplasty propably..
Frist or all I will order CBC ( looking for leukocystosis)
Then Xray on the big toe AP and laterl views ( looking for osteomyelitis)
I will do culture and senstitvity from the wound for proper antibiotic choice
This patient is WIFI SCORE (W1I1FI 1)which means low risk for amputation
Starting the Antiobiotic empircal unitl Cand S appears
Then pateint will undergo transbrachial/crossover angioplasty of the external iliac ,CFA,SFA andtibials (Because of hostile groin for thr previous operation)
If failed retrograde angioplasty may be considered
After doing the angioplasty I will asses the pedal pulse and wavform by HHD
Then I will do surgical debridment and follow up for any recurrent infection
Then I will apply complete offloading ( as the big toe esp this area ulcerated is one the pressure points of the foot) ( By RCB)
with daily dressing and follow up for the wound
I may use the Vac for formation of granlation tissue
1 proposed managment
Hx taking : risk factors for DFI; diabetic control, HTN, comobidities of PAD as IHD and CVD
Examination : general if pt is toxic/ septic due to infection – BP and HR. Local Exam including distal pulses and if there is any collection in the foot, probe to bone testing in case of deep ulcer
Basic investigations: CBC- leucocytosis , S crt , wound culture and sensitivity, Duplex US on arterial system including the patency and flow form in the arterial tree, prescence of atherosclerotic plaques and their respective percent stenosis of the associated vessels
initial TTT include hospitilization with vitals monitoring, starting with antibiotic coverage and to be adjusted after C and S, IV fluids if not overloaded, Diabetic control and maintaining adequate Blood glucose control
assessment for the possibility of incision drainage of the foot if there is detectable collection within necrotic tissue
revascularization
proposed plan in endovascular in this case as pt has previous femoral exposure with subsequent adhesions
– cross over access for angioplasty of the proximal sfa (stenosis and long segment CTO)
if failed trial retrograde access through one of the crurals -preferably the ATA as it’s patent proximally
passage of the wire with escalation whether retrograde or antegrade
vessel preparation with lithotrepsy can help improve outcome
patient will propably require stenting given subintimal wire passage and the long segment lesion
after revascularization; big toe ray amputation
A –
admission of patient
start sepsis 6 give patient o2 and antibiotics and fluids
withdraw full lab and lactate and blood culture -crp – lipid profile -HBA1c
measure ABI and duplex of ll and cta
our options
1 contralteral angioplsty
its advantage avoid open surgery especially in redo endarterectomy
give us a working distance
its cons less pushability and we may cant cross this long TCO in sfa
2 retrograde approach
it help us with crossing the lesion
but it may disrupt our only run off
3 hybrid technique through redo endartectomy
and proximal angio
and fem pop bypass using aynthetic graft or we may try distal angio
its cons it os a redo surgery so there is more risk of injury to fhe vessels and infection to wound
graft problems either infection or thrombosis
Hospitalization as a case of CTLI with DFI
Resuscitation with normal saline
Iv broad spectrum antibiotics
RBS detection and rapid control proceeded
Lap investigations ( cbc-crp-creat-Hba1c-lipid profile-creat)
Radiology x ray foor , ankle
——
Surgical intervention: evacuation of pocket of pus , mild debridement
Diabetologist consultation for glycemic control
Anathesologist consultation for surgical intervention
Pre op preparation ( good hydration – decline of sepsis markers – undercover of antibiotics- good urine out put )
Operation::
Plan A contralateral femoral access with iliac dilitation and cfa dilitaion then ipsilateral access by sheath 6 then sfa , pob, tibial angioplasty
Then ballon 5 inflation at cfa for 5 minutes post removal of sheath( mechanical closure of ostium)
——
Plan B
Rt femoral endarterectomy and retrograde iliac angioplasty then antegrade sfa ballon dilitation and pop angioplasty
——-
Plan c
Trans brachial access
Passing wire till tibials
Atherectomy device use at level of iliac, sfa, pop
——
Plan D
Open iliofemoral bypass
Fem- tibial bypass
——
Then big toe amputation
Pt with RT L.L chronic limb threatening ischemia accompanied with RT DFI.
needs:
-Urgent hospital admission.
-IV fluids resuscitation
-Labs: CBC , Coagulation profile, Renal functions, electrolytes
-Plain X-ray of RT foot to exclude osteomyelitis or MRI
-Empirical I.V antibiotics, antipyretics
-Urgent drainage of abscess
-Culture and sensitivity tests and bone biopsy
-Control diabetes
Then prepare patient fo urgent revascularization:
-Endovascular by contralateral approach from LT CFA to access the RT CIA then revascularization of RT EIA, CFA, SFA, Pop A, PTA and peroneal A + stenting of RT EIA.
This is a good option to be avoid the RT groin wound and due to history of RT CFA endarterectomy, but may be difficult to access the RT infragenicular portion of RT Popliteal and crural vessels.
-Hybrid by combining both RT CFA redo endarterectomy with venous patch closure and RT iliac artery angioplasty with stenting to restore the inflow, then distal angioplasty.
-Hybrid: CFA redo endoarterectomy and angioplasty of RT iliac vessels with stenting.
then Fempop infragenicualr bypass using synthetic PTFE graft.
However the synthetic graft not recommended due to risk of infection from spesis.
-Pharmacological medications: best medical treatment should be considered using vasodilators, statins, antiplatelets.
-Wound care : hyperbaric O2 or VAC therapy.
-Endocrinologist for control of Diabetes
-Podiatrist for care of foot
-Nutritionist for diet control
admission and resuscitation iv fluids and antibiotics and control of glycemic level
x-ray and assessment of the infection extent
arrange for drainage surgery to eradicate the septic focus
arrange for revascularization endovascular which gives us option to treat the multilevel disease we have in the angiography and given a history of previous femoral exploration
the endovascular option for CFA may compromise the profanda femoris ostium and may need stenting which is still not evidenced and needs more study to assess its efficacy
if failed hybrid can be done with femoral endarterctomy using bovine patch due to lack of suitable conduit and EIA angioplasty and femoro-Pop(P3) bypass in this option too much steps if you need to full reavscularize the foot in such extensive wound
A case of RT L.L chronic limb threatening ischemia accompanied with RT DFI.
She needs:
-Urgent hospital admission.
-IV fluids resuscitation
-Labs: CBC , Coagulation profile, Renal functions, electrolytes
-Plain X-ray of RT foot to exclude osteomyelitis
-Empirical I.V antibiotics, antipyretics
-Urgent drainage of abscess
-Culture and sensitivity tests
-Control diabetes
Then prepare patient fo urgent revascularization:
-Endovascular by contralateral approach from LT CFA to access the RT CIA then revascularization of RT EIA, CFA, SFA, Pop A, PTA and peroneal A + stenting of RT EIA.
This is a good option to be avoid the RT groin wound and due to history of RT CFA endarterectomy, but may be difficult to access the RT infragenicular portion of RT Popliteal and crural vessels.
-Hybrid by combining both RT CFA redo endarterectomy with patch closure and RT iliac artery angioplasty with stenting to restore the inflow, then distal angioplasty.
-Hybrid: CFA redo endoarterectomy and angioplasty of RT iliac vessels with stenting.
then Fempop infragenicualr bypass using synthetic PTFE graft.
However the synthetic graft not recommended due to risk of infection from spesis.
-Pharmacological medications: best medical treatment should be considered using vasodilators, statins, antiplatelets.
-Wound care : hyperbaric O2 or VAC therapy.
-Endocrinologist for control of Diabetes
-Podiatrist for care of foot
-Nutritionist for diet control
Patient in this case has critical limb ischemia associated with diabetic foot infected ulcer so she needs urgent admission and multi-disciplinary management by internal medicine for DM control, also cardiology to control codex cardiac and hypertension
Investigations full lab including CBC, serum creatinin, serum urea CRP alt AST and INR, culture and sensitivity
X rat foot post ant and lat veiws: to exclude osteomyelitis and gas formation if yes we may proceed to amputation
Regarding vascular intervention the patient had iliac stenosis common femoral artery stenosis and flush lesion sfa till the P3 Segment with continued anterior tibial artery only as the distal run off
I prefer to start endo-vascular approach via left brachial access, traversing the CIA, CFA, SFA, till the tibials
It is a challenge, if difficult, we can try hybrid approach (CFA ENDARTRECTOMY+ retrograde iliac angioplasty, SFA and trial of tibial angioplasty)
if failed, fem-pop 3 bypass is the option in the same session.
foot debridement will be done according to level of infection Just Post-operatively
69 year old lady presented with rt CLTI she had prior history of revascularization . And now presented with foot ulcer with signs of infection in the form of redness and tenderness .. management will start by patient admission and starting emberical antibiotic treatment while labs are obtained . CBC ,KFT, LFT, CRP, ECG, and foot X-ray
then anaesthesia consultation for patient fitness for surgery
This patient has and angiography showing multilevel vascular lesion EIA, CFA, SFA with single run off ATA
I THINK hypried approach here is so good with redo CFA endarterectomy and patch-plasty
Then iliac angioplasty and stenting
With long bypass from CFA to ATA by synthetic graft
It is a long and exhausting operation but
For this multi level disease and long SFA occlusion it is a reasonable option to get long straight blood flow line to the foot
However the long term patency og synthetic graft is questionable and not as durable as native graft
So post operative graft surveillance and life long antipletlets and low dose revaroxiban is advised
Post revascularization wound depridement is required together with proper wound offloading and dressing
Admission
Resuscitation iv antibiotics and fluids
Labs cbc crp for sepsis
Imaging xray for deep infection gas FB OM
Endocrinologist and nutritionist for diabetes control
Anesthesiologist for fitness
Evaluation of his neurological condition regarding the ulcer mixed cause
Prepare for urgent drainage and debridement together with c/s with big toe amputation to be considered along with revascularization
Revascularization options
1: endovascular because of multiple levels lesions and previous groin wound full correction angioplasty of EIA CFA SFA POP PTA PERONEAL
2: hybrid redo CFA EA then closure with vein or bovine patch for infection and continue angioplasty retrograde for iliac and distal for sfa pop and tibials with difficulty regarding angioplasty of the pop behind the knee
3: hybrid EA of Cfa angioplasty of the EIA and fem pop BTK bypass graft synthetic to P3 with cuff which is not the best option due to infected foot after angioplasty of the tibials to secure distal run off for graft patency
These options done in parallel with the BMT, antibiotics according to culture by microbiologist for ttt of infection, offloading by orthotist, podiatrist for wound care management and dressings, physiotherapy for rehabs