LIVE CASE PRESENTATION MOUNT SINAI CARDIAC CATH LAB NEW YORK MARCH 8, 2017

HISTORY OF PRESENT ILLNESS Patient is a 75 year old male with a history of hypertension, hyperlipidemia, CAD s/p CABG History of PVD s/p failed left femoral to popliteal bypass x 2 at outside hospitals Has had left 3rd and 4th toe amputations Now presents with left dorsal foot ulcer and dry gangrene as well as ulceration between the 2nd and 5th toes (Rutherford Grade IV; Category 6; Fontaine Stage IV)

PAST MEDICAL HISTORY Hypertension Hyperlipidemia PVD s/p failed left femoral to popliteal bypass x 2 in 2013 and 2016 CAD s/p CABG 12/2000 Ischemic Cardiomyopathy s/p ICD CHF DVT right lower extremity on anticoagulation

MEDICATIONS ALLERGIES ASA Clopidogrel SOCIAL HISTORY Atorvastatin Carvedilol Lisinopril Aldactone Xarelto ALLERGIES NKMA SOCIAL HISTORY Smoking: 40 pyh. Quit 10 years ago Alcohol Use: Occasional Drug Use: None FAMILY HISTORY None ROS Negative aside from above

Vital- BP 140/84 Pulse 70 Resp 14 Afebrile Neck- No carotid bruits PHYSICAL EXAMINATION Vital- BP 140/84 Pulse 70 Resp 14 Afebrile Neck- No carotid bruits CV- RRR no murmurs/rubs/gallops Resp- CTAB Ext- Ulceration and dry gangrene dorsum of left foot. Ulceration between 2nd and 5th toes. Left DP and PT pulses reveal poor doppler signals. LABS HGB 10.1 PLT 129 CR 0.64 INR 1.3

ABI: Right ABI 0.61. Left ABI 0.35.

CASE PRESENTATION SUMMARY 75 year old male with PVD, hypertension, hyperlipidemia, CAD who presents with a left foot ulceration and dry gangrene consistent with critical limb ischemia Left foot ABI of 0.35 with severely blunted waveforms Peripheral angiogram reveals severe left SFA and infrapopliteal disease S/P left SFA PTA / Viabahn stent / Zilver stent x 2 and s/p left TPT PTA / Xience stent Plan: Left infrapopliteal intervention