1. Division of Endovascular Interventions
Mount Sinai Hospital
New York
05/16/18

2. History and Physical 71 year old, female
HTN, type 2 DM, CKD (baseline creatinine 1.6), PAD (right BKA)
Non-healing ulcer on medial aspect of left first toe with rest pain
Meds -Aspirin, metoprolol, HCTZ, lipitor, insulin
BP - 144/76 mmHg
Pulse - 64/min
monophasic DP signal, no PT signal

3. Labs and work up Hb- 10.8 g/dl Platelets- 161K INR- 1.1
Creatinine- 1.6
ABI: 0.53
Duplex: ‘moderate disease in SFA, occlusion of AT and PT in mid segment’
‘Conservative therapy’ was recommended. Referred for second opinion

4. Strategy Right CFA access 6F,45 cm crossover sheath
Therapeutic anticoagulation- Bivalirudin
Antegrade lesion crossing
DP access if antegrade approach fails
PTA
Drug eluting stent for flow limiting dissection

5. Angiosome directed therapy

7. Angiosome directed therapy

8. Angiosome directed therapy

9. Pedal-plantar arch

13. Wound blush and healing

14. Summary Direct inline flow/ Angiosome directed therapy
If pedal arch is present, either vessel may be selected
In absence of good angiographic targets, good wound blush should be the goal

17. Multidisciplinary approach