56 yrs male
C/O:
bilateral IC, L>R, left foot rest pain
Claudication distance: 100 yards, can’t do his job
PMH:
DM, IHD, Ex-smoker
What investigations will you ask for?
What risk factors would you control?
What are the findings of the CT?
What treatment options would you consider?
What interventions would you recommend?
Q1
Echo , pulmonary function tests, CBC ,kFts, lipid profile,HbA1c, BMI
Q2
Try to control and correct modifiable risk factors
Statin, control blood sugar , obesity
Q3
Total lt CIA+EIA occlusion
Rt CIA +EIA stenosis
Q4
Aorto bifemoral by pass
PTS (CERAB or kissing stent)
Q5 CERAB
‘Q1: investigations to be required are full lab ;CBC ,BLEEDING PROFILE,RBG,HBA1C, KFTS, LFTS and lipid profile
Cardiopulmonary evaluation; ECG,ECHOCARDIOGRAPHY, STRESS ECG,PULMONARY FUNCTION TEST
Q2Risk factors divided into modifiable and non modifiable
Modifiable;
Cessation of smoking
Control DM
STATINS
Antiplatlets
Anticoagulant
Supervised exercise
Q3
CTA shows
lt side: total occlusion of CIA,EIA
RT side : CIA ,EIA stenosis
Q4 ttt optios OSR(ABFBG)EXTRAANATOMICA BYPASS
ENDOVASCULAR (KISSING STENT,CERAB
Q1
Echo , pulmonary function tests, CBC ,kFts, lipid profile,HbA1c, BMI
Q2
Try to control and correct modifiable risk factors
Statin, control blood sugar , obesity
Q3
Total lt CIA+EIA occlusion
Rt CIA +EIA stenosis
Q4
Aorto bifemoral by pass
PTS (CERAB or kissing stent)
Q5 CERAB
1 Investigation CBC inr lft kft lipid profile ecg echo duplex cta
2 strict diabetic control hyperlipidemia stop smoking diet exercise
3 finding total occlusion Lt iliac common ext stenosis rt
4 bmt endovascular open
5open
What investigations will you ask for?
full lab including renal function lipid profile , HbA1C
Stress Echo or Cardio pulmonary exercise test.
CTA on the whole aorta with both lower libs to detect any femoral or popliteal occlusion
What risk factors would you control?
Hyper lipidemia with maximum dose statins
Diabetes control
Dual anti platlet
What are the findings of the CT?
total occlusion of the Left CIA with some calcification
What treatment options would you consider?
there’s two options OSR or Endovascular
OSR include Aorto-bifemoral if the patient is fit
Axillo bifemoral or Fem-Fem bypasss
Endovascular include kissing stent- CERAB- or AFX graft
What interventions would you recommend?
both Aorto bifemoral and kissing stent are good options and according to the patient preference as long as the patient is fit for OSR and there’s available facility for endovascular with ESVS 2024 guidlines recommending OSR
“For patients with disabling intermittent claudication undergoing revascularisation who are considered as low risk with long life expectancy, open surgery may be considered for Trans-Atlantic Inter-Society Consensus Document II C/D lesions that include the iliac arteries as well as the aorta up to the renal arteries, due to favourable primary and secondary patency rates compared with endovascular approaches. Class Level References ToE IIb B Salem et al. (2021)536 Premaratne et al. (2020)537 Indes et al. (2013)538 Starodubtsev et al. (2022)539”
Q1: full bloods including renal function and lipid profile, CTA abdominal Aorta and both LL. he also has a history of IHD which should be will evaluated for assessment of the cardiac risk by ECG first and then decide whether need further investigations such as Echo or not
Q2: control DM, smoking( already stopped), hyperlipidemia if present.
Q3: patent infra renal Aorta, total flush occlusion of left CIA with run off in CFA (TASC D), patent left profuda A. Patent right CIA, EIA and femoral A. some calcification at the abdominal Aorta, iliac and femoral vessels.
Q4: options for treatment
surgical options, Aotro bifemoral bypass, fem- fem cross over, axillo fem bypass. +/- Lt CFA endarterectomy
Endovascular options: angioplasty of lt iliac arteries + kissing iliac stents either covered or BES
Q5: the patient is young, so depending in his fitness, if he is fit for OSR I will go for Aorto bifemoral bypass +/- LT CFA endarterectomy due to favorable primary and secondary patency rate (ESVS 2024 Recommendation 58 class IIb level B)
if not fit for OSR, I will recommend covered iliac kissing stents . (ESVS 2024 Recommendation 57 class IIb level B) due to higher patency rates. +/- LT CFA endarterectomy, (ESVS 2024 Recommendation 60 class I level C)
Q1: Full labs, CTA
Q2: stop smoking, control DM and HTN
Q3: Rt CIA and EIA stenosis and Lt CIA and EIA total occlusion
Q4: control RF with BMT , Aotrobifem bypass or Endovascular treatment
Q5: Iwill recommend Endovascular treatment using kissing stents
Q1. CBC KFT LFT PT INR RBS FBS HbA1C lipid profile.
ECG ECHO
Q2 DM IHD
Q3.mild calcification of aorta and Stenotic Rt CIA ostium with occluded lt CIA EIA refilling on CFA
Q4.Endovascular or open surgery
Q5. Endovascular with kissing stents