ENDOCRINE ROUNDS CASE 5- PERIPHERAL ARTERIAL DISEASE

An elderly female with long standing history of uncontrolled diabetes mellitus presents with non-healing ulcer over the tip of the 2nd right toe with blackening of both left and forefoot since last 2-3 months.
The ABPI was 0.55 on the right side and 1.36 on the left

Q. What is the interpretation of the ABPI ?

On the right side ABPI is suggestive of significant PAD on the with ABPI >1.3 is difficult to interpret with ABPI alone and would suggest a non compressible vessel.
Right arterial doppler showed biphasic flow in the ATA with reduced pressure and PTA was found to be Stenosed at the origin.
The CT peripheral angiography of the lower limb was done and show below

Right

1- Popliteal

2- Anterior tibial

3- posterior tibial

4- peroneal

Left

1- Popliteal

2- Ant. tibial

3- tibioperoneal trunk

5- peroneal

6 – posterior tibial

Q. What is your interpretation of CT angiography ?
The posterior tibial on both side has attenuated lumen and significant reduction in flow

Q. What would be the next step for this patient ?
The next step would be to perform a revascularization procedure

Q. How to decide which revascularization procedure to perform in this case.
It depends on TASC classification of lesion.

Q. Which TASC stages would do well with Angioplasty
TASC A- single lesion < 5 cm
TASC B- multiple lesions, each <5 cm

Q. Is infrapopliteal angioplasty successful ? What is the long term patency rate ?
Success is >90%, however the term patency rate is 42% at 2 years with conventional balloon angioplasty.

Q. Which TASC lesions would require surgical revascularization ?
TASC C – Multiple stenosis with total length of occlusion > 10 cm
TASC D- Occlusion length >10 cm with dense lesion calcification and non visualization of collaterals

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