Question 1

Before discussing any surgical options, what kind of cardiac evaluation would you consider as appropriate in this case?

A.  ECG and transthoracic echocardiography B.  Stress echocardiography

C.  Coronary computed tomography angiography (CCTA) D.  Coronary angiography

This patient had no previous myocardial infarction and no clinical sign of myocardial ischemia. The ECG and cardiac echography were considered as normal. No further cardiac evaluation was considered in this case. [Q2-A]

Question 2

Which of the following surgical options will you consider in this case?

A.  Aortobifemoral bypass (ABF) with distal anastomosis on both profunda femoris arteries B.  Percutaneous bilateral iliac stenting with left external iliac recanalization

C.  Bilateral iliac stenting with left external iliac recanalization and bilateral femoral bypass to the profunda

D.  Right iliac stenting with right femoral bypass to the profunda and crossover femorofemoral bypass to the left profunda

E.  Right iliac stenting with a right femoral to profunda endarterectomy with patch plasty and crossover femorofemoral bypass to the left profunda

Fig. 18.1  Percutaneous angiography with brachial artery catheterization using the Seldinger technique. Early film sequence showing severe stenosis of the right common iliac artery, stenosis of the left common iliac artery and occlusion of the left external iliac and femoral arteries

Fig. 18.2  Percutaneous angiography showing a moderate stenosis of the right external iliac artery, that was found to be significant on color duplex with PSV > 3.5 m/s

Fig. 18.3  Percutaneous angiography. Delayed film showing late revascularization of the profunda femoris arteries with occlusion of the right common femoral artery and significant disease of the left common iliac artery

An hybrid technique [Q3-D] was used in this case with stenting of the right common and external iliac arteries associated with a right bypass to the profunda and a crossover femorofemoral bypass to the left profunda. Option [Q3-E] was also considered as an alternative, but not used in this case, considering the extensive lesions in the right

profunda femoris artery. Option [Q3-C] was considered also as a possibility but impossible to achieve due to the extension of the iliac lesions into the left common femoral artery.

Question 3

Which of the following will be part of your follow-up management?

A.  Prescription of aspirin B.  Prescription of statins

C.  Enrolment of the patient in a supervised exercise program

D.  Follow up at 6-month and then every year with a color duplex scan and ankle brachial index measurement

E.  Smoking cessation advice with psychological and specific drug therapy if needed F.  All of the above

All of these options were offered to the patient who registered in a supervised exercise program but didn’t quit smoking completely. Rest pain disappeared, mild claudication withawalkingdistanceof600mwasconsideredasacceptablebythepatientandimproved gradually further.

18.1  Commentary

This patient has a chronic critical limb ischaemia (CLI) caused by iliac and infrainguinal atherosclerotic disease. This most advanced form of peripheral arterial disease is associated with a high risk of cardiovascular events that include major limb loss, myocardial infarction and death.1–4 In these cases, the 5 year life expectancy is approximately 50%.5,6 Considering the high-risk nature of the CLI population, as well as the number of treatment options, precise risk evaluation is necessary in such a case.

18.2 

Clinical Assessment

We used in this case, the PREVENT III CLI Risk Score7,8 which is an easy to use risk stratification model developed to predict amputation free survival in patients with peripheral arterial disease. This relatively young patient (<75 years), who was not on dialysis, had no tissue loss and no clinical coronary disease was considered as a low risk case (Score < 3) with a high probabilityto be alive at 1-yearwith intact lower limbs. In thiscase,