CASE REPORT

AORTOILIAC OCCLUSIVE DISEASE

Redi Rulandani

Pembimbing :
dr.Teguh Marfen Djadjakusumah,Sp.B,Subsp.BVE(K)
• Identitas pasien :
Nama : Tn. D
Usia : 43 tahun
Jenis kelamin : Laki-laki
Pekerjaan : wiraswasta
 )
ANAMNESIS
KU : Kebiruan pada jari 1-5 kaki kanan
AK :
Pasien mengeluhkan kebiruan pada jari 1-5 kaki dekstra sejak dua belas hari sebelum
masuk rumah sakit. Keluhan kebiruan diawali dari ujung jari 1-5 kaki kanan kemudian menjalar sampai
mata kaki kanan, bengkak (+) , nyeri saat istirahat (+). Riwayat sesak (-). Riwayat trauma (-). Riwayat
keluhan nyeri tungkai saat berjalan dan membaik saat istirahat (+). Riwayat sulit ereksi sejak 3
bulan yang lalu. Riwayat tekanan darah tinggi (-). Riwayat DM (-). Riwayat kolesterol tinggi (-), Riwayat
stroke (-), penyakit jantung (-), Riwayat TB (-). Riwayat DM dalam keluarga (-). Riwayat merokok (+) sejak 15
tahun lalu, sebanyak 2 bungkus/hari. Pasien sebelumnya dirawat di RS Al Islam dan sudah dilakukan USG
doppler ekstremitas inferior sinistra dan diberikan heparin bolus namun tidak diberikan heparin
maintenance saat dirujuk.
Karena keluhan tidak membaik, pasien dirujuk ke IGD Bedah RSHS untuk mendapatkan
tatalaksana lebih lanjut.
 Tn. Deddy Suparlan / L / 43 tahun / 0002164801 / BPJS
MRS : 23-07-2023
Ruangan : RIK 4
DPJP : dr. Teguh Marfen Djajakusumah, M.Kes., SpB., Subsp.BVE(K)

Leriche syndrome ec thromboemboli dengan faktor resiko Merokok yang telah dilakukan thrombectomy
ektremitas inferior dekstra (RSHS, 23 Juli 2023) + anemia (perbaikan) + Riwayat thrombectomy extremitas inferior
dextra (RSHS, 24-07-2023 ) yang telah dilakukan Bypass aorto bifemoral + Clamping aorta (RSHS, 7 Agustus 2023)
yang telah dilakukan Above Knee Amputation + Thrombectomy POD 5
Temuan Intraoperatif RSHS, 11-08-2023
DO:
• Ditemukan gangrene pedis dekstra, jaringan nekrotik
(+), pus (-) slough (-)
• Dilakukan identifikasi a. femoralis profunda diameter
5mm, dinding tidak menebal, thrombus (+) menutup
seluruh lumen, pancaran (-), pulsating (-)
• Dilakukan amputasi above knee dextra -> otot dan
kulit pada batas amputasi kesan viable
• Dilakukan trombektomi a. femoral superfisialis ->
trombus (+), pancaran (++), pulsating (+)
• Ditemukan jaringan dan tulang pada level amputasi
kesan vital
 Tn. Deddy Suparlan / L / 43 tahun / 0002164801 / BPJS
MRS : 23-07-2023
Ruangan : RIK 4
DPJP : dr. Teguh Marfen Djajakusumah, M.Kes., SpB., Subsp.BVE(K)

Leriche syndrome ec thromboemboli dengan faktor resiko Merokok yang telah dilakukan thrombectomy
ektremitas inferior dekstra (RSHS, 23 Juli 2023) + anemia (perbaikan) + Riwayat thrombectomy extremitas inferior
dextra (RSHS, 24-07-2023 ) yang telah dilakukan Bypass aorto bifemoral + Clamping aorta (RSHS, 7 Agustus 2023)
yang telah dilakukan Above Knee Amputation + Thrombectomy POD 5
Temuan Intraoperatif RSHS, 07-08-2023
DO:
• Ditemukan pulsasi arteri aorta abdominalis (++),
pancaran (++)
• Ditemukan pulsasi arteri femoralis komunis dekstra
(-), pancaran (+)
• Ditemukan pulsasi arteri femoralis komunis sinistra
(+), pancaran (++)
• Ditemukan Hard plaque dari Aorta infrarenal
sampai a. Common femoral bilateral
• Dilakukan Bypass Aorto-Bifemoral dengan Unigraft
dacron KDV 16x8mm--> pulsasi a. Common
femoralis dekstra (++), flow (++), pulsasi a.
Common femoralis sinistra (++), flow (++)
 Tn. Deddy Suparlan / L / 43 tahun / 0002164801 / BPJS
MRS : 23-07-2023
Ruangan : RIK 4
DPJP : dr. Teguh Marfen Djajakusumah, M.Kes., SpB., Subsp.BVE(K)

Leriche syndrome ec thromboemboli dengan faktor resiko Merokok yang telah dilakukan thrombectomy
ektremitas inferior dekstra (RSHS, 23 Juli 2023) + anemia (perbaikan) + Riwayat thrombectomy extremitas inferior
dextra (RSHS, 24-07-2023 ) yang telah dilakukan Bypass aorto bifemoral + Clamping aorta (RSHS, 7 Agustus 2023)
yang telah dilakukan Above Knee Amputation + Thrombectomy POD 5

Temuan Intraoperatif RSHS, 24-07-2023

DO:
• Ditemukan arteri femoralis komunis diameter 1 cm, dinding tidak menebal,
pulsasi (+), trombus (-), teridentifikasi superficial femoral artery dan profunda
femoral artery
• Dilakukan arteriotomy + insersi fogarty ukuran no 3 ke arah distal dan
proximal- Post trombektomy —> flow pancaran (++), backflow (++), pulsasi (+
+), trombus (+)- Dilakukan flush unfractional heparin ke dalam pembuluh
darah ke arah distal
 PEMERIKSAAN FISIK
STATUS GENERALIS :
Kesadaran : Compos mentis
Keadaan umum : Tampak sakit sedang
Tanda vital : T : 105/51 mmHg N : 80x/mnt R : 20 x/mn
S : 36.5oC SpO2 : 97% udara bebas
Ar Kepala : konjungtiva anemis (-/-), sklera ikterik (-/-)

STATUS LOKALIS :
Ar thoraks : Bentuk dan gerak simetris, VBS Kanan = Kiri, Rhonki -/-, Wheezing -/-
Cor: BJ 1 dan 2 dalam batas normal, regular
Ar abdomen : datar dan lembut, BU (+) Normal, NT (+) area operasi, NL (-), DM (-),
 PEMERIKSAAN FISIK
STATUS LOKALIS :
Ar. Ekstremitas inferior dextra
I : Edema (+), hiperemis (+) sianosis(+), jar. ulkus (-), bullae (-), jaringan nekrotik (-), pus (-) rambut jarang (-)
atrofi otot (-)
SaO2 jari 1 : 0 %SaO2 jari 2 : 0 %SaO2 jari 3 : 0 %SaO2 jari 4 : 0 %SaO2 jari 5 : 0 %
P : akral teraba dingin, nyeri tekan (+), sensibilitas sensorik berkurang dibandingkan dengan sisi sebelahnya,
pulsasi a. dorsalis pedis (-), a. tibialis posterior (-), a. poplitea (-), a. femoralis (-)
M : ROM sulit digerakkan

Ar. Ekstremitas inferior sinistra

I : Edema (-), gangrene (-), ulkus (-), bullae (-), kebiruan (-), rambut jarang (-) atrofi otot (-)
SaO2 jari 1 : 0 %SaO2 jari 2 : 0 %SaO2 jari 3 : 0 %SaO2 jari 4 : 0 %SaO2 jari 5 : 0 %
P : Akral dingin, nyeri tekan (-), sensibilitas sensorik (-), pulsasi a. dorsalis pedis (-), a. tibialis posterior (-), a.
poplitea (-), a. femoralis (-)
M : ROM sulit digerakkan
 STATUS VASKULAR

++ ++ ++ ++

++ ++

- -

ABI Kanan : tidak dapat dinilai

- - ABI kiri : tidak dapat dinilai

- -
- -

-
FOTO KLINIS
 FOTO KLINIS
POST BY PASS
 FOTO KLINIS
POST AMPUTASI ABOVE KNEE
FOTO POLOS DADA
RSHS, 03-08-2023
 USG DOPLER
RSUD AL ISLAM, 20-07-2023

KESIMPULAN:
Oklusi plak thrombus arteri poplitea dextra dan tidak
tampak aliran signal vaskuler di bagian distal arteri
tibialis anterior maupun posterior dextra,
mengesankan adanya acute peripheral arterial
occlusive disease. Thrombus intralumen vena poplitea
dextra [0,3 x 0,4 x 0,62 cm], masih compressible pada
test kompresi dan masih tampak signal aliran
vaskuler.
CT ANGIOGRAPHY AORTA
RSHS, 01-08-2023
MSCT Angiografi:
- Tampak aorta abdominalis mempercabangkan truncus
Coeliacus, arteri mesenterika superior, arteri mesenterika
inferior dan arteri renalis kanan dan kiri. Aorta abdominalis tidak
menyempit.
- Arteri mesenterika Superior: Lumen tidak menyempit, dinding
reguler, tidak tampak lesi hipodens intraluminal.
- Arteri Renalis kanan dan kiri: Lumen tidak menyempit, dinding
reguler, tidak tampak lesi hipodens intraluminal.
- Tampak oklusi total di distal aorta abdominalis. Tidak tampak
adanya kolateralisasi arterial.
KESIMPULAN:
- Total oklusi pada distal aorta abdominalis. Tidak tampak
adanya kolateralisasi arterial
 ECHOCARDIOGRAPHY
RSHS, 02-08-2023

KESIMPULAN:
- normal all chamber dimension
- normal LV systolic function (EF Eyeballing 55-60%) with normokinetic
at rest
- normal LV diastolic dysfunction
- normal all valves and function, low probability of PH
- normal RV systolic function
 LABORATORIUM
Laboratorium 23-07-2023 24-07-2023 25-07-2023 26-07-2023 26-07-2023 27-07-2023 27-07-2023
(07.00) (20.00) (08.00) (20.00)
PT/aPTT/INR -/-/- 13.0/29.70/ 12.7/27.6/0. -/36.10/- -/28/- -/44.5/- -/30.1/-
0.88 86
Hemoglobin 7.9 8.4 10.2
Hematokrit 27.5 29.8 34.6
Leukosit 21.360 22.000 18.160
Trombosit 877.000 670.000 527.000
GDS 79 82
SGOT/SGPT 121/185 -/-
Na/K 139/4.0 -/-
Ur/Cr 39.4/1.10 -/-
Albumin 3.42 -
Rapid Antigen Negatif -
Cov-19
 LABORATORIUM

Laboratori 28-07- 28-07- 29-07- 29-07- 30-07- 31-07- 01-08- 01-08- 02-08-
um 2023 2023 2023 2023 2023 2023 2023 2023 2023
(09.00) (20.00) (10.00) (20.00) (15.22) (08.00) (20.00) (08.00)
PT/aPTT/ -/34.1/- -/40.1/- -/32.6/- -/30.5/- -/30.60/- -/31.2/- -/28.8/- -/30.30/- -/30.00/-
INR
Hemoglobin 11 11.1
Hematokrit 36 36.6
Leukosit 19.070 17.360
Trombosit 476.000 569.000
SGOT / 59 / 100
SGPT
Ur / Cr 25.3 /
1.09
 LABORATORIUM
Laboratorium 03-08-2023 04-08-2023 05-08-2023 07-08-2023 08-08-2023
(post op)
PT/aPTT/INR 13.1/28.7/ 0.89 13.6/30/ 13.5/30.60/0.9 16.1/47.90/1.11 14.8/31.0/1.01
0.95 4
Hemoglobin 10.7 10.5 7.6 8.4
Hematokrit 35.3 35.3 25.3 27.1
Leukosit 14.740 15.880 16.190 15.000
Trombosit 693.000 798.000 528.000 453.000
GDS 106
SGOT/SGPT 38/64
Na/K 136 / 4.6 139/4.2 137/4.9
Ur/Cr 22.9/0.87 14.5/0.60 22.8/0.63
Kolesterol total / 129/ 27 / 89
HDL / LDL
Trigliserida 90
Albumin 3.44 1.90 2.16
 LABORATORIUM

Laboratorium 09-08-2023 10-08- 10-08-2023 11-08-2023 11-08-2023 12-08- 13-08-

2023 (17.00) 2023 2023
(05.00)
PT/aPTT/INR 12.9 / 0.88 / 12.2 / 12.5 / 12 / 20 / 13.7 / 12.7 / 13.5 /
28.4 28.7 / 29.7 / 0.84 0.81 49.6 / 0.95 30.8 / 0.88 27.8 / 0.94
0.83
Hemoglobin 8.2 10.2 11 - 10.1 -
Hematokrit 26.4 33.1 35 - 31.8 -
Leukosit 17.370 12.620 16.690 - 11.320 -
Trombosit 527.000 584.000 563.000 - 830.000 -
GDS 132 - - -
SGOT/SGPT 33 / 32 -- - -
Na/K 133 / 4.8 134 / 4.5 135 / 5.3 - - -
Ur/Cr 26 / 0.75 - - -
 LABORATORIUM

Laboratoriu 05-08- 07-08-2023 08-08-2023

m 2023
Asam Laktat 1.7 2.4 1.3
AGD

pH 7.520 7.370 7.420

pCO2 22.7 36.5 36.6

pO2 87.7 184.5 177.2

HCO3 18.9 21.2 23.8

tCO2 19.6 22.4 24.9

BE -1.6 - 3.0 0.1

Sat O2 97.9 99.1 99.4

TATALAKSANA :
• Observasi TTV, BU, Drain/24jam, tanda tanda perdarahan
• IVFD NaCl 1500cc/24 jam
• Heparin maintenance 18000 U/24 jam, target APTT 1,5-2,5 kali dari baseline
• Paracetamol 3x1g IV
• Omeprazole 2 x 40 mg IV
• Meropenem 3x1 gr IV
 Leriche Syndrome -
Aortoiliac Occlusive Disease
(AIOD)
 Leriche syndrome or aortoiliac occlusive disease (AIOD)

1.Definition
Caused by severe atherosclerosis in
the distal abdominal aorta, iliac
arteries and femoro-popliteal
vessels.

2.Triad:
a.Claudication
b.Impotence In this patient
c.Absence of femoral pulses

Pascarella L, Aboul Hosn M. Minimally Invasive Management of Severe Aortoiliac Occlusive Disease. J Laparoendosc
Adv Surg Tech A. 2018 May;28(5):562-568.
 Classification of PAD
1. Based on severity of symptoms
a. Rutherford
b. Fountaine

2. Based on location: Bollinger classification

1: abdominal aorta
2: common iliac
3: external iliac
4: internal iliac
5: profunda
6: superficial femoral
7: popliteal
8: anterior tibial
9: peroneal
10: posterior tibial
Hardman RL, Jazaeri O, Yi J, Smith M, Gupta R. Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 2014
Dec;31(4):378-88. doi: 10.1055/s-0034-1393976. PMID: 25435665; PMCID: PMC4232437.
 Classification of Aortoiliac Occlusive Disease

• Extend and Localization of

atherosclerotic occlusion define
the classification of the disease.
• Type I: only distal
abdominal aorta and
common iliac arteries

Nanto K, Iida O, Fujihara M, et al. Five-Year Patency and its Predictors after Endovascular Therapy for Aortoiliac Occlusive Disease. Journal of Atherosclerosis and
Thrombosis. 2019 Nov;26(11):989-996. DOI: 10.5551/jat.45617. PMID: 30996200; PMCID: PMC6845694.
 Classification

• Type II: distal abdominal

aorta with disease extension
to common iliac and
external iliac
• Type III: aortoiliac
segment and
femoropopliteal vessels

Nanto K, Iida O, Fujihara M, et al. Five-Year Patency and its Predictors after Endovascular Therapy for Aortoiliac Occlusive Disease. Journal of Atherosclerosis and
Thrombosis. 2019 Nov;26(11):989-996. DOI: 10.5551/jat.45617. PMID: 30996200; PMCID: PMC6845694.
 Classification

• TASC Classification

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 Etiology
Caused by atherosclerosis
- :
Modifiable risk factors
Non-modifiable risk factors:
- Hypertension
- Age
- DM - Gender
- Race
- Nicotine - Family history
- Hyperlipidemia
- Hyperglycemia

Frederick M, Newman J, Kohlwes J. Leriche syndrome. J Gen Intern Med. 2010 Oct;25(10):1102-4.
 Prevalence

1. Increases in aging population.

2. 14% for patients older than 69 years of age.

Frederick M, Newman J, Kohlwes J. Leriche syndrome. J Gen Intern Med. 2010 Oct;25(10):1102-4.
 Pathophysiology

Frederick M, Newman J, Kohlwes J. Leriche syndrome. J Gen Intern Med. 2010 Oct;25(10):1102-4.
 Diagnostic Evaluation

• Laboratory Parameters:
• Serum lipid profile (total cholesterol, LDL, HDL, TG)
• HbA1c (if diabetic)
• Lipoprotein A
• Reduced ABI
• Color duplex scanning: either peak systolic velocity ration ≥ 2.5 at site
of stenosis or a monophasic waveform
• MRA and multidetector CTA can determine extend and type of
obstruction.
• Patient should be subjected to angiography only if symptoms warrants
surgical intervention

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 Differential Diagnosis

1. Degenerative hip or spine disease (breakdown of the cartilage in

your hip joint)
2. Lumbar disc herniation
3. Spinal stenosis
4. Diabetic neuropathy

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 General Treatment Consideration

1. No effective medical therapy, but control of risk factors may help

(control of hypertension, hyperlipidemia and DM, stop smoking)
2. Antiplatelet therapy
3. Graduated exercise program
4. Failure to respond to exercise or drug therapy -> limb
revascularization

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 Surgical Reconstruction

• Aortobifemoral Bypass
a. Performed because patients usually have
disease in both iliac systems
b. Has long-term patency (70-80% at 10 years) and
has a tolerable perioperative mortality (2-3%)
c. Can be end-to-end anastomosis or side-to-side
anastomosis

End-to-end anastomosis

Side-to-side anastomosis
Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.
 Surgical Reconstruction

• Aortic Endarterectomy
a. Useful when disease is
localized to either aorta or
common iliac arteries,
b. However now, aortoiliac
PTA (Percutaneous
Transluminal Angioplasty),
stens, and other catheter-
based therapy became
first-line

• Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

• Sidawy, Anton N., and Perler, Bruce A.. Rutherford's Vascular Surgery and Endovascular Therapy, 2-Volume Set. United States, Elsevier
Health Sciences, 2022.
 Surgical Reconstruction

• Axillofemoral Bypass
a. For patients with medical comorbidities that prevents abdominal vascular
reconstruction

• Ileofemoral Bypass
a. For patients with medical comorbidities that prevents abdominal vascular
reconstruction

• Femorofemoral Bypass
a. Patients with unilateral stenosis or occlusion of common or external iliac
artery who have rest pain, tissue loss, or intractable claudication

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 Surgical Reconstruction

• Obturator Bypass
For patients with groin sepsis resulting from prior prosthetic grafting, intra-
arterial drug abuse, groin neoplasm or damage from prior groin irradiation

• Thoracofemoral Bypass
Indications:
i. Multiple prior surgeries with failed infrarenal aortic reconstruction
ii. Infected aortic prosthesis

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 Complications of Surgical Reconstruction

• Early postoperative hemorrhage (1-2%)

• Acute limb ischemia after surgery due to acute
thrombosis or distal thromboembolism.
• Intestinal ischemia (2%)
• Late complications: reocclusion,
pseudoaneurysms, and infection (21% in 22 year
period follow-up), most common: graft
thrombosis
• most prone: aortofemoral reconstructions and
axillofemoral bypass

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 Endovascular Treatment: Aorta

• Focal Aortic Stenosis

Bilateral CFA access is established followed by insertion of
6F sheath. Self-expanding nitinol stent or balloon-
expendable implanted followed by adequate post dilation.
Single stent is usually adequate.

• Occlusive Lesions of Aortic Bifurcation

• Treated with kissing balloon technique to avoid
dislodging aortic plaque
• Positioned across ostia of common iliac arteries, using
retrograde approach and inflated.

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 Endovascular Treatment: Iliac
• Percutaneous Transluminal Angioplasty
For treatment of isolated iliac stenoses of less than 4cm
in length
For stenosis: 2 year patency of 86%
Complication rate: 2%

• Primary Stenting vs Selective Stenting

• Primary patency rates: 1 year (96%), 2 years (90%), and
3 years (72%)
• Selective patency rates: 1 year (46%), 2 years (46%),
and 3 years (28%)
• Primary stenting:
• Chronic iliac artery occlusions
• Recurrent stenosis after previous iliac PTA
• Complex stenoses with eccentric, calcified,
ulcerated plaques
• Plaques with spontaneous dissection
Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.
 Endovascular Treatment: Iliac

• Stent Graft Placement

• Used to treat complex iliac lesions to exclude sources of embolization
• Primary patency rate of 91.1% in 1 year

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

Chronic Limb-Threathening
Ischemia
 Chronic Limb Threatening Ischemia

Definition
Is the end-stage of peripheral artery disease (PAD), characterized by chronic,
inadequate tissue perfusion at rest and associated with high risk of limb amputation,
Duration >2 weeks

Pascarella L, Aboul Hosn M. Minimally Invasive Management of Severe Aortoiliac Occlusive Disease. J Laparoendosc
Adv Surg Tech A. 2018 May;28(5):562-568.
 Epidemiology

1. Prevalence: 1-2%, but can be as high as 11% for patients with

known PAD
2. Over 5-year period, 5-10% of patients with asymptomatic PAD or
intermittent claudication can progress to CLTI.
3. Independently associated with:
• Advanced age,
• Smoking
• DM
• Chronic renal dysfunction

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Causes
CLTI can be caused by:
1. Atherosclerosis
2. Thromboembolism
3. Buerger’s disease
4. Trauma
5. Dissection
6. Vasculitis
7. Fibromuscular dysplasia

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Pathophysiology

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Evaluation

1. Limb Pain/Numbness
1. Worse with elevation and lessen with dependency (level of limb lower than
level of heart)
2. If patient has diabetes, foot wounds are painless
2. Physical Exam:
1. Absence of ankle pulses
2. Dependent rubor
3. Thin or shiny skin
4. Increased capillary refill time
5. Absence of hair
3. Diagnostic Approach:
1. ABI measurement
2. Doppler waveforms

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Evaluation

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Evaluation

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Evaluation

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Treatment

1. Goal of treatment: relieve pain, heal wounds, preserve functional limb, and
improve QoL.

Cellulitis -> broad-spectrum antibiotics Revascularization is attempted if

Abses -> incisional drainage infection is controlled

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Treatment

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Treatment

Farber A. Chronic limb-threatening ischemia. New England Journal of Medicine. 2018 Jul 12;379(2):171-80.
 Treatment: Open Surgical Approach

1. Indication
• Lifestyle-limiting claudication
• Ischemic rest pain
• Tissue loss/gangrene
• Certain lesions that are not amendable for endovascular treatment
1. Long segment occlusion
2. Heavily calcified lesions
3. Or lesions that cannot be transversed by a guidewire.

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 Treatment: Endovascular Approach

1. Percutaneous Transluminal Balloon Angioplasty

• 90% success rate and 38-58% 5-year primary patency rates
• Depends highly on anatomic selection and patient condition
• Longer lesions (7-10cm) offers limited patency, and shorter lesions (<3cm)
has good results
2. Subintimal Angioplasty
• Recommended for chronic occlusion, long segment of lesion and heavily
calcified lesions
3. Stent Placement
• Primary indication: potential salvage of an unacceptable angioplasty result
• Typically used when residual stenosis after PTA is >30%.
• Also used when occlusive lesions that have a tendency for re-occlusion and
distal embolization after PTA.

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.

 Treatment: Endovascular Approach

4. Atherectomy
• To remove the atheroma of obstructed arterial vessels by cutting and
removing or pulverization.
• Laser atherectomy: use of UV energy to ablate the lesion and create non
thrombogenic arterial lumen

Brunicardi FC. Schwartz’s principles of surgery. McGraw-Hill Education.; 2019.