Dialyzed patients with critical limb-threatening ischemia, no-option, or not?

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Hsuan-Li Huang, MD
ISEVS Japan Chapter
​Program Director

Director-Peripheral vascular center,
​Division of Cardiology, Taipei Tzu-chi Hospital, New Taipei, Taiwan  ​

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Clinical History

This 74-year-old female patient has a history of type II diabetes mellitus, coronary artery disease, and end-stage renal disease undergoing regular dialysis. She presented with an unhealing ankle ulcer of the right foot for a couple of weeks (Figure 1). Endovascular therapy (EVT) was attempted, but in vain before the referral. Her ankle-brachial pressure index at the right leg is 0.72 (93 mmHg).  ​

Figure 1

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Procedure

Figure 2

​The angiography is performed via the right antegrade approach, which revealed isolated below-the-knee disease with preserved anterior tibial, dorsalis pedis, and peroneal arteries but posterior tibial (PTA) and lateral plantar arteries (LPA) are occluded.

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The intervention started with 4 F 45 cm shuttle tibial sheath (Cook) in 6 F Terumo sheath to increase support. We used a 0.014 Command (Abbott) guidewire supported by 0.018 CXI catheter (Cook) to cross the long-occluded PTA. The wire went smoothly down to the ankle due to prior intervention. However, the wire cannot advance into LPA. Rendezvous technique via pedal arch cannot gain success. During the wire manipulation, the PT2 guidewire went through another channel with low resistance. The tip injection of contrast medium showed the wire was located in the posterior tibial vein. We used the 2.5 mm Amphirion balloon catheter to create the arteriovenous (AV) channel between the lateral plantar vein (LPV) and LPA. The final result showed the rapid blood flow to the ankle site via this AV channel. ​

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Conclusions/Results

Figure 3

After the EVT, the wound pain improved, and the duplex ultrasound revealed the remarkable increase of blood flow in the LPA and pulsatile waveform spectrum in LPV. The ankle pressure went up to 136 mmHg three days after the EVT, which was in line with increased ankle perfusion by radionuclide arteriography. This wound healed completely 2.5 months after the EVT. 

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​​In conclusion, planned or unplanned AV channel creation holds some promise to avoid major amputation in dialyzed patients with possible no-option critical limb-threatening ischemia. ​​