1. Multi-territory Revascularization: A Sisyphean TASC?
Kush Agrawal, MD*
With special thanks for contributions to:
Thomas N. Carruthers, MD¶
Jeffrey Kalish, MD¶
Robert T. Eberhardt, MD*
Boston Medical Center
¶Department of Vascular and Endovascular Surgery
*Department of Medicine, Division of Cardiology and Vascular Medicine

2. 73 y/o M with symptomatic CAD presenting with toe gangrene
Left Leg PAD:
External Iliac Artery stent 2001
Severe Claudication 2010: 40% common iliac stenosis, occluded distal SFA and below-knee popliteal/trifurcation, 2-vessel runoff.
Intolerant of Pletal
Rest Pain 7/2013: CFA endarterectomy and patchy angioplasty. Inflow felt adequate, no CIA intervention.
Minor trauma 10/2013 to 2nd toegangrene.

3. 73 y/o M with symptomatic CAD presenting with toe gangrene
Other Past Medical/Surgical History:
Hypertension (25+ years)
Former Smoker (quit 1990, 45 Pack-Year history)
Non-insulin dependent diabetes mellitus
Bilateral 50-60% carotid stenosis.
Right Leg PAD: Fem-Pop bypass 2001, complicated by subacute thrombus in summer 2012, treated with popliteal and AT stenting.
Medications:
Amlodipine 10mg
Isosorbide Mononitrate 120mg qhs
Aspirin 81 mg
HCTZ 25mg
Lisinopril 40mg
Clopidogrel 75mg
Metoprolol Succinate 50mg
Atorvastatin 40mg
Nitroglycerin 0.4mg SL prn
Metformin 1000mg bid
Amoxicillin/Clavalunate 500 bid x7d

4. Symptomatic CAD
1990: 3vCABG: LIMA to LAD, SVG-RCA, jump SVG-Diag-OM (upper pole) –OM (lower pole)
2007: Unstable Angina (UA): 60% Left Subclavian stenosis, patent LIMA, occluded SVG-RCA.
2009: NSTEMI: BMS to Left Subclavian (SC), DES to lower pole OM graft (1st layer of stent scaffolding)
2011: UA: DES x2 (overlapping) to SVG-OM (2nd layer)
2/2012: UA: Native Cors: 95% Left Main, 70% prox LAD, 100% prox LCx, 100% prox RCA. POBA to in-stent restenosis (ISR) of SC stent (40mmHg gradient); BMS upper pole SVG-OM.

5. Symptomatic CAD
4/2012: UA, Rest Angina: Repeat POBA to SC stent and repeat DES to SVG-OM (3rd layer)
8/2012: NSTEMI, Rest Angina: Brachytherapy for SVG-OM: 95% ISR, 50% recoil post-treatment, used cutting balloon that caused edge thrombus. Passage of Spider distal filter caused thrombus embolization to retrograde limb of LCx (asymptomatic). Recoiled stented segment of SVG-OM treated with 4.5 x 38mm Ultra BMS, post-dilated to 5.0 mm (4th layer!).
From 2012 to present: suffering from progressive stable angina, CCS II to III at present, most prominently angina decubitus. Had gastrointestinal upset with ranolazine and was maximized on isosorbide mononitrate with stable symptoms, but tenuous cardiac status with little reserve.

6. Part 1 CLI Revascularization: Left Subclavian Angioplasty
Left Brachial Access 6F Sheath, Monitored Anesthesia Care
40mmHg gradient at Left SC artery.
7 x 20mm NC balloon, high pressure inflation
10mmHg residual gradient

7. Part 2 CLI Revascularization: Diagnostic Angiography
Left Ileofemoral (s/p Patch Angioplasty)
Iliac Angiogram
85% ostial LCIA lesion. 80mmHg translesional gradient.
60% LCFA stenosis at site of patch angioplasty.

8. Part 2 CLI Revascularization: Diagnostic Angiography
mid-SFA, mid-profunda occlusion
w/ reconstitution above knee
Collateral flow below knee reconstitutes mid-calf
AT to DP runoff to foot;
Diminished PT/Peroneal

9. Part 2 CLI Revascularization: Which Approach?
★ At this point, we encountered a critical Juncture. He was too high risk for an open surgical repair, the procedure of choice. Furthermore, autologous veins for bypass were unavailable, as they were used in prior CABG and R leg bypass.
★The endovascular approach
1) afforded no plaque reduction options (atherectomy) owing to location and risk,
2) would require bilateral covered iCAST stent in a “kissing” fashion at the aortic bifurcation,
3) and necessitated upsizing the brachial sheath to a 7F, which would mandate brachial surgical cutdown for sheath removal.
★Given his aforementioned tenuous cardiac status, the case was halted, a multidisciplinary conference was held between the patient’s Cardiologist (R.T.E), Endovascular Surgeon (J.K.) and the patient, and ultimately the endovascular approach was chosen, because we had reasonable confidence in success with the ultimate outcome being relief of rest pain and improved inflow to the gangrenous toe.

10. Part 2 CLI Revascularization: Left Iliac Intervention
Step 2. Measurements w sizing catheter
Step 1. Right Iliac System Accessed

11. Part 2 CLI Revascularization: Left Iliac Intervention
Step 3. Up-size to 7F, 90cm sheath from L Brachial
Step 4. Deploy iCAST balloon-expandable “kissing” covered stents (left) w/ reconstruction of aortic bifurcation (right)

12. Part 3 CLI Revascularization: Left CFA Patch Intervention
6mm x 40mm high-pressure inflation
Then 8mm x 40mm low-pressure inflation.
Residual stenosis that was not flow-limiting.

13. 3-week Follow-up Palpable left DP Pulse Resolution of rest Pain.
Improved healing
and confinement
of gangrene
Stable angina.

14. Multi-territory Revascularization: When are our repeated efforts not fruitless? Take Home Points:
Multi-territory Revascularization requires a multidisciplinary “team” approach to patient care, balancing interdependence of, in this case, of thoracic, coronary, and peripheral ischemia.
A thoughtful assessment of the merits and risks of operative vs. endovascular revascularization is paramount, and the constraints of the anatomic guidelines in TASC I and II can underserve patients’ needs. TASC III will aid in making more circumspect decisions.
Creativity (eg. recognizing need for subclavian angioplasty a priori in this case), the ability to” stop-and-go” during the procedure, and communicating honest expectations (best confidence in a particular outcome) early on ensure the best possible outcome in very complicated cases such as this one.
Kush Agrawal, MD*
With special thanks to:
Thomas N. Carruthers, MD¶
Jeffrey Kalish, MD¶
Robert T. Eberhardt, MD*
¶Department of Vascular and Endovascular Surgery
*Department of Medicine, Division of Cardiology and Vascular Medicine