Case Report Peripheral Arterial Disease Vaskular 2015

Endovascular Intervention For Nearly Occlusion Left Popliteal Artery in Tangerang Hospital

Novrizal Saiful Basri, Kemas Dahlan, Ismon Kusasi

Vascular and Endovascular Division, Department of Surgery, Ciptomangunkusumo National Hospital

Faculty of Medicine University of Indonesia

Abstract

Introduction

Peripheral arterial disease (PAD) is a leading cause of death worldwide. The important risk factors are smoking, diabetes mellitus, hypertension, and hypercholesterolemia. Advances in the diagnosis and successful treatment of PAD have occurred rapidly, and now include broader use of noninvasive duplex ultrasonography (US) and minimally invasive endovascular techniques. This report describes a case of peripheral artery disease that had been done balloon angioplasty as the choice of treatment rather than open surgery.

Case Report

We report a 52-years-old man presented to the outpatient clinic with a chief complaint of a wound at his right foot for 2 months. The complaint started 2 months ago when his foot was blackened and being amputated then. Until now the patient is still in the wound care. Patient also complaint pain on his feet especially after he walked. This patient has a history of amputation 8 years ago on his 4th and 5th phalanx. There is no history of diabetes mellitus and hypertension. The physical examination showed positive one on bilateral dorsalis pedis and posterior tibial. The ABI was 0.8/0.8. An arteriography was performed with an access from the left femoral artery and the result was 8,5 cm length near total occlusion of the popliteal artery. Then a balloon angioplasty was performed on the right popliteal artery occlusion and an angiography was performed, the occluded part was opened.

Conclussion

Peripheral arterial disease (PAD) manifestation include some type of pain range from no symptoms to intermittent claudication to critical limb ischemia (CLI). History or clinical risk factors are important in making diagnosis. Measurement of the ankle-brachial index (ABI) is the primary method for establishing the diagnosis of PAD. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal

angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably.

Introduction

Peripheral arterial disease (PAD) is a leading cause of death worldwide. The important risk factors are smoking, diabetes mellitus, hypertension, and hypercholesterolemia. Advances in the diagnosis and successful treatment of PAD have occurred rapidly, and now include broader use of noninvasive duplex ultrasonography (US) and minimally invasive endovascular techniques. 1-3 This report describes a case of peripheral artery disease that had been done balloon angioplasty as the choice of treatment rather than open surgery.

Case Presentation

Male, 52 years old presented to the outpatient clinic with a chief complaint of a wound at his right foot for 2 months. The complaint started 2 months ago when his foot was blackened and being amputated then. Until now the patient is still in the wound care. Patient also complaint pain on his feet especially after he walked. This patient has a history of amputation 8 years ago on his 4th and 5th phalanx. There is no history of diabetes mellitus and hypertension. The physical examination showed positive one on bilateral dorsalis pedis and posterior tibial. The ABI was 0.8/0.8

Figure 1 and 2. Clinical Pictures.

An arteriography was performed with an access from the left femoral artery and the result was 8,5 cm length near total occlusion of the popliteal artery.

Figure 3. Before balloon angioplasty arteriography.

Then a balloon angioplasty was performed on the right popliteal artery occlusion and an angiography was performed, the occluded part was opened.

Figure 4. Balloon angioplasty.

Figure 5. After Balloon angioplasty arteriography.

After the balloon angioplasty, patient was given :

- Heparin bolus 5000 IU followed by heparin 20000 drip IU / 24 hours- Clopidogrel 1x75 mg- Cilostazol 2x50 mg- Xartel 1x20 mg

First day post operative laboratorium :

PT/apTT 20.6 (14.4)/61.2(33.1)

Second day post operative laboratorium

2/7/15 12.9(14.5)/36.7(36.4)

Patient was discharged at the third day.

Discussion

Chronic lower extremity ischemia, also known as peripheral arterial disease (PAD), is the most common cause of loss of normal walking ability seen by the vascular specialist. The manifestations of chronic lower extremity ischemia usually include some type of pain and are produced by varying degrees of muscle ischemia; they range from no symptoms to intermittent claudication to critical limb ischemia (CLI). History, physical exam, and noninvasive tests are nearly always sufficient to make the diagnosis of peripheral arterial disease (PAD). 1-4 In present case, the patient complain of unhealing wound with intermitten claudication.

Clinical risk factors based on literature and journals are cardiac history, cerebrovascular history, current smoking, diabetes mellitus, dyslipidemia, hypertension, prior percutaneous coronary intervention, prior coronary artery bypass graft, and prior myocardial infarction. Measurement of the ankle-brachial index (ABI) is the primary method for establishing the diagnosis of PAD. An ABI of <0.90 has been demonstrated to have high sensitivity and specificity for the identification of PAD compared with the gold standard of invasive arteriography. 5-7 In this case, the patient only has history of smoking without other clinical risk factors. The ABI of both limbs were 0.8/0.8.

Surgical and endovascular therapy (EVT) are likely to be similar in efficacy overall, although the quality of supporting evidence comparing the two is poor and the likelihood of durable clinical success different. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery. Catheter arteriography represents the gold standard due to superior image resolution and the unique ability of being able to perform a diagnostic study and EVT at the same time. Arguably, as long as endovascular intervention does not negatively affect a patient’s option to have an open surgery in the event of restenosis or reocclusion, endovascular intervention can be attempted for even complex lesions.4,7,8 In this case, arteriography and balloon angioplasty were choose as the main diagnostic study and treatment because of the less morbidity and more effective.

In conclusion, peripheral arterial disease (PAD) manifestation include some type of pain range from no symptoms to intermittent claudication to critical limb ischemia (CLI). History or clinical risk factors are important in making diagnosis. Measurement of the ankle-brachial index (ABI) is the primary method for establishing the diagnosis of PAD. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous

transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably.

References:

1. Cronenwett JL, Johnston KW. Vascular Surgery 7th edition. Philadelphia, PA .2010

Elsevier Inc

2. Rasmussen TE, Clouse WD, Tonnessen BH. Handbook of Patient Care in Vascular

Diseases 5th edition. USA, 2008 Lippincott Williams & Wilkins.

3. Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, et al. Comparison of global

estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a

systematic review and analysis. Lancet. 2013 Oct 19;382(9901):1329-40

4. Goldstein LB, Silva MB Jr., Choi L, Cheng CC. Peripheral arterial occlusive disease. In:

Townsend CM Jr., Beauchamp RD, Evers BM, Mattox KL.Sabiston Textbook of

Surgery.

5. Van Zitteren M, et al., One Year Health Status Benefits Following Treatment for New

Onset or Exacerbation of Peripheral Arterial Disease Symptoms: The Importance of

Patients’ Baseline Health Status, European Journal of Vascular and Endovascular

Surgery (2015), http://dx.doi.org/10.1016/j.ejvs.2015.04.003

6. Welten GMJM, Schouten O, Hoeks SE, Chonchol M, et al. Long-Term Prognosis of

Patients With Peripheral Arterial Disease A Comparison in Patients With Coronary

Artery Disease. JACC Vol. 51, No. 16, 2008 Welten et al. 1589

7. Conte MS, Pomposelli FB, Clair DG, Geraghty PJ, et al. Society for Vascular Surgery

practice guidelines for atherosclerotic occlusive disease of the lower extremities:

Management of asymptomatic disease and claudication. JOURNAL OF VASCULAR

SURGERY March Supplemen 2015 : Volume 61, Number 3S

8. Allaqaband S, Kirvaitis R, Jan F, Bajwa T. Endovascular treatment of peripheral vascular

disease. Curr Probl Cardiol. 2009 Sep;34(9):359-476. doi:

10.1016/j.cpcardiol.2009.05.001.