Objective follow up is a hallowed tradition and a necessary feature in vascular surgery. Non-invasive testing, particularly when there has been a pre-treatment study available for comparison, is convenient and cost effective.1,2,16 This study, when compared with the pre treatment study demonstrates improved waveform and pressure indexes on the right (secondarytothebaremetalstentplacedintherightiliac).Thepressureindexesandwaveform on the left are greatly improved as are the hallux pressures and waveforms (secondary to the covered stent reconstruction of the left superficial femoral artery). [Q10: F]

Although clopidogrel can be an expensive medicine it is considered to be of patient benefit following stent grafting in the infrainguinal arterial segment following long segment subintimal arterial reconstruction. This patient’s symptoms and non-invasive testing results are distinctly abnormal. The new lab test reveals limb arterial flow that has deteriorated from the initial post reconstruction study, obtained 5 months earlier to establish a surveillance baseline (Figs. 19.13 and 19.14). Ischemia to this degree of severity is frequently associated with rest pain. Matters seem to have been made worse by the obvious debris in the tibial peroneal trunk and origin of the anterior tibial artery (Fig. 19.16) not seen in the previous images (Figs. 19.6 and 19.12). It is likely that this represent a recent embolus from the more proximal segment that is now occluded (Fig. 19.15). [Q11: E]

There is no controversy that autogenous conduit is preferred for arterial reconstruction bypass operation, particularly when the target for the distal anastomosis is below the knee.17,18 However, the authors believe that there are a few circumstances when vein depletion (for example from: multiple vein harvests for coronary artery bypass grafts, long standing chronic hemodialysis, extensive prior vein phlebectomies, long standing intravenous drug abuse, previous amputations, post phlebitis leg syndrome or congenital vascular anomalies) may make autogenous conduit use either impractical or impossible. A Utopian mindset on the part of an actual operating Vascular Surgeon seldom if ever serves the patient well. [Q12: F]

References

 1. Norgren, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;451S.

 2. Hirsch At, Haskal ZJ, Hertzer NR, et al. Guidelines for the management of patients with peripheral arterial disease. J AM Coll Cardiol. 2006;47:1239-1312.

 3. Brooks B, Dean R, Patel S, Wu B, Moyneaux L, Yue DK. TBI or not TBI: that is the question. Is it better to measure toe pressure than ankle pressure in diabetic patients? Diabet Med. 2001;18:528-532.

 4. Grollman JH, Marcus R. Transbrachial arteriography: techniques and complications.

Cardiovasc Intervent Radiol. 1988;11:32-35.

 5. Watkinson AF, Hartnell GG. Complications of direct brachial artery puncture for arteriography: a comparison of techniques. Clin Radiol. 1991;44:189-191.

 6. Heenan SD, Grubnic S, Buckenham TM, Belli AM. Transbrachial arteriography: indiations and complications. Clin Radiol. 1996;51:205-209.

 7. Schmieder G, Richardson A, Scott E, Stokes G, Meier G, Panneton J. Selective stenting in subintimal angioplasty: analysis of primary stent outcomes. J Vasc Surg. 2008;48:1175-1181.

 8. Treiman G, Treiman R, Whiting J. Results of percutaneous subintimal angioplasty using routine stenting. J Vasc Surg. 2006;43:513-519.

 9. Scott E, Biuckians A, Light R, Burgess J, Meier G, Panneton J. Subintimal angioplasty: our experience in the treatment of 506 infrainguinal arterial occlusions. J Vasc Surg. 2008;48: 878-884.

10.Sarac T, Altinel O, Bannazadeh M, Kashyap V, Lyden S, Clair D. MidTerm outcome predictors for lower extremity procedures. J Vasc Surg. 2008;48:885-890.

11.Chung SW, Sharafuddin MJ, Chigurupati R. Midterm patency following atherectomy for infrainguinal occlusive disease: a word of caution. J Vasc Surg. 2008;48:1634.

12.McCarthy WJ, Vogelzang RL, Nemcek AA, et al. Excimer-laser-assisted femoral angioplasty:Early results. J Vasc Surg. 1991;13:607-614.

13.Dearing D, Patel K, Compoginis J, Kamel M, Weaver F, Katz S. Primary stenting of the superficial femoral and popliteal artery. J Vasc Surg. 2009;3:542-547.

14.Surowiec SM, Davies MG, Eberly SW, et al. Percutaneous angioplasty and stenting of the superficial femoral artery. J Vasc Surg. 2005;2:269-278.

15.Dosluoglu HH, Cherr GS, Lall P, Harris L, Dryjski M. Stenting vs above knee olytetrafluoroethylene bypass for TransAlantic Inter-Society Consensus-II C and D superficial femoral artery disease. J Vasc Surg. 2008;5:1166-1174.

16.Ahn SS, Rutherford RB, Becker GJ, et al. Reporting standards for lower extremity arterial endovascular procedures. J Vasc Surg. 1993;17:1103.

17.Mills JL. P values may lack power: the choice of conduit for above-knee femoropopliteal bypass graft. J Vasc Surg. 2000;32:402-405.

18.Veith FJ, Gupta SK, Ascher E, White-Flores S, et al. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg. 1986;3:104-114.

Jean Starr and Patrick Vaccaro

A 72 year old non-smoking female with a past medical history of hypertension, wellcontrolled diabetes, and stable coronary artery disease, status post CABG with bilateral great saphenous vein harvests, presents to her podiatrist. She developed an ulcer over the right first metatarsal head after wearing a new pair of shoes approximately 4 months ago. The wound is gradually getting larger, despite appropriate local wound care and off-loading procedures. She is referred to you for evaluation for arterial insufficiency.

Physical examination reveals normal and equal bilateral femoral pulses with no palpable distal pulses. There are well-healed, bilateral medial thigh incisions. The toes are pink with brisk capillary refill. There is diminished sensation to fine touch bilaterally, but normal motor function is noted. The ulcer base is pale with fibrinous debris. There is no foul odor or obvious cellulitis.

Question 1

The best first step in her evaluation and/or management is:

A.  Operative debridement to eliminate necrotic tissue and bone and initiation of oral antibiotics, based on culture results.

B.  Lower extremity arterial Dopplers with waveforms. C.  MRA of the lower extremities.

D.  Angiography with possible intervention. E.  Start Cilostazol and a walking program.

The ankle-brachial indices are greater than one and a digital brachial index is 0.6 bilaterally. Upper thigh waveforms are multiphasic; popliteal and pedal waveforms are monophasic. Exercise testing was not performed due to her inability to walk on a treadmill.

J. Starr ( )

Division of Vascular Diseases and Surgery, The Ohio State University, Columbus, OH, USA

Question 2

Which of the following is true?

A.  ABIs correlate well with long-term survival in PAD patients.

B.  DBIs are an unreliable measure of PAD in diabetic patients due to small vessel calcification.

C.  A direct popliteal artery pressure measurement of greater than 50 mmHg helps to predict a positive outcome after angioplasty.

D.  A pulsus tardus waveform on a lower extremity arterial duplex examination correlates with adequate arterial perfusion.

An aortogram with runoff was performed via the left femoral artery and showed a normal aortoiliac segment with a 20 cm left superficial femoral artery (SFA) occlusion and diffuse tibial stenoses with contiguous flow into the foot. The right superficial femoral artery showedthreeareasoffocalstenosiswiththeproximalandmidlesionsmeasuring1cmand the distal measuring 2 cm in length (Fig. 20.1). The most distal lesion ended proximal to the adductor canal. The popliteal artery had no significant stenosis. The right posterior tibial and peroneal arteries were totally occluded and did not provide any collateral flow into the foot (Fig. 20.2). The anterior tibial artery had several areas of distal stenoses, all proximal to the ankle. The most severe was just above the ankle joint (Fig. 20.3). There was no complete pedal arch, but abundant collateral flow in the foot was present.

Fig. 20.1  Right SFA tandem stenoses