Treatment for no-option CLTI patient

In the past decade, patients affected by chronic limb-threatening ischemia (CLTI) have increased, mostly due to a rise in population age and diabetes. In about 15-20 % of CLTI patients, arterial revascularisation is not possible, or not effective (no-option). Severe MAC-score is an independently factor of redo-treatment, persistent ischemia and major amputation, despite a successful arterial revascularisation.

Bruno Migliara

Peschiera del Garda, Italy

Part I - Case presentation

A 79 year-old male patient

Comorbidities:

arterial hypertension;
type 2 diabetes;
atrial fibrillation
chronic renal disease (GFR 31 ml / min)

Foot presentation

Right foot: previous amputation of the first toe and metatarsal bone for wet gangrene (in another hospital, without revascularisation)
Necrosis of the surgical site due to the CLTI (TcpO2 = 3 mmHg)
WIfI class = 2-3-1

Quiz answer

Timing: revascularisation before, foot surgery after
Surgical/endovascular arterial revascularisation is the first treatment choice in case of CLTI, in order to increase oxygen and nutrition in the ischemic area.

Treatment choice

Angiography: patency of the anterior tibial, but occlusion of the dorsalis pedis; patency of peroneal; occlusion of posterior tibial
Foot X-ray: diffuse calcification in the foot arteries (MAC-score = 5)

Part II - Our treatment

Due to the presence of severe MAC score and no distal artery for bypass surgery, the treatment choice is foot venous arterialisation.

Based on the angiography, percutaneous-DVA could be considered the first choice, because arterial flow into the foot is supplied by the anterior tibial and peroneal arteries

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