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

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

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

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.

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

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

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

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.

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

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. 2009 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;312:1396-1397.

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.

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

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.

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

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?