Case and Plan:
53-year-old woman with progressively worsening LLE claudication progressing to rest pain over the past 3 months (Rutherford class 4).
•Worsening symptoms despite maximal medical therapy and community based SET
•PMH: HTN, Hyperlipidemia DM, former smoker, poly-vascular disease (CAD s/p CABG in 2022 and PAD s/p prior PTAs)
•Pertinent focused vascular exam notable for non palpable but dopplerable DP and PT bilaterally
•Medications: Aspirin 81 mg, rivaroxaban 2.5 mg BID, Atorvastatin 80 mg, Evolocumab, zetia Insulin, Dulaglutide, Empagliflozin Cilostazol
•Arterial Duplex was notable for patent L SFA stent, L posterior tibial and ATA occluded proximally, ATA reconstitutes in the mid segment with distal ATA with monophasic waveforms.
•6 Fr RFA Up and over 45 cm destination sheath
•Alternate access: Pedal access distal ATA in the foot
•Attempt antegrade crossing with support catheter
•If unsuccessful antegrade cross retrograde via pedal access and externalize the wire through the antegrade catheter and treat from above
•IVUS guidance sizing and plaque morphology, try lumen vs subintimal
•Vessel Prep (Atherectomy, IVL , Atherotomy)
•PTA, BTK Everolimus Eluting Resorbable Scaffold System
