The Impact of Repeat Endovascular Treatment on Critical Limb-Threatening Ischemia for Limb Salvage

Abstract

Chronic limb-threatening ischemia due to chronic total occlusion of below-the-knee lesions is one of the most challenging cases for endovascular treatment. Restoring perfusion is crucial, and its success depends on numerous factors. Owing to the recent development of dedicated devices and techniques, endovascular treatment is becoming an alternative to bypass surgery as a first-line treatment, even for the infra-popliteal lesion, because endovascular recanalization outcomes have considerably improved. In our present case, a self-expandable Nitinol stent was placed in the tibio-peroneal trunk to treat chronic limb-threatening ischemia. At its recurrence four years later, endovascular therapy was employed because the patient had concomitant diseases and advanced age. Finally, four times repeated revascularization prevented major amputation and preserved the functional foot. This report demonstrates that repeated endovascular therapy was practical and feasible to achieve limb salvage and preserve the functional foot.

Keywords: below-the-knee stenting; bypass surgery; chronic limb-threatening ischemia; limb salvage; repeat endovascular treatment.

Figure 1. Contrast-enhanced computed tomography (CECT) image

Both the anterior tibial artery (ATA) and the posterior tibial artery (PTA) were jailed by the SMART stent (red arrow) and the peroneal artery (yellow arrowhead) could be only detected.

Figure 2. The diagnostic angiography of the first attempt.

Figure 3. White arrow; IVUS. (A) The retrograde wire and microcatheter (black arrow). (B) IVUS image: SMART stent (red arrowhead), dense calcified plaque (white arrowhead), IVUS image core (asterisk). (C) Wire-tail penetration into the stent.

IVUS = intravascular ultrasound

Figure 4. The final angiography of the first attempt.

Figure 5. The final angiography after the fourth EVT.