CASE REPORT
Su bin t im a l a n giopla st y w it h ou t st e n t in g on a pa t ie n t w it h com ple x foot
le sion
Be r na r do M a ssiè r eI; Cle oni Pe dr onI; Ar no von Rist owI I; José M ussa Cur yI; M a r cus Gr e ssI; Albe r t o Ve scoviI; M a r cos Ar e a s M a r que sI; Ant onio Luiz de M e dinaI I I
IVascular surgeon. Associat e physician, Cent ervasc- Rio, Rio de Janeiro, RJ, Brazil. Professor, Graduat e Program in Vascular Surgery, Pont ifícia Universidade Cat ólica do Rio de Janeiro ( PUCRJ) , Rio de Janeiro, RJ, Brazil.
I IVascular surgeon. Direct or, Cent ervasc- Rio, Rio de Janeiro, RJ, Brazil. Associat e professor, Graduat e Program in Vascular Surgery, PUC- Rio, Rio de Janeiro, RJ, Brazil.
I I IVascular surgeon. Professor, Graduat e Program in Vascular Surgery, PUC- Rio, Rio de Janeiro, RJ, Brazil.
Correspondence
J Vasc Bras. 2008; 7( 2) : 155- 158.
ABSTRACT
Diabet ic pat ient s present ing w it h bot h peripheral vascular disease and com plex soft- t issue defect s are oft en t reat ed by prim ary am put at ion. We report t he case of a 66- year- old fem ale pat ient wit h m ult iple com orbid condit ions. She present ed left foot plant ar abscess and TASC C superficial fem oral lesion. Endovascular revascularizat ion of t he left lower lim b was perform ed em ploying t he subint im al angioplast y t echnique, wit hout st ent ing or endograft ing. This com bined approach of lower lim b revascularizat ion associat ed w it h int ensive care in diabet ic foot wounds should always be considered before am put at ion. We recom m end subint im al angioplast y as an opt ion for high- risk pat ient s w it h com plex lim b wounds.
Ke yw or ds: Subint im al angioplast y, lower lim b, diabet ic foot .
RESUM O
angioplast ia subint im al com o um a opção em pacient es de elevado risco cirúrgico port adores de feridas com plexas nas ext rem idades.
Pa la vr a s- cha ve : Angioplast ia subint im al, m em bro inferior, pé diabét ico.
I n t r odu ct ion
Diabet ic pat ient s wit h peripheral art erial occlusive disease and ext ensive soft t issue lesions are frequent ly t reat ed by prim ary am put at ion. Lim b revascularizat ion associat ed wit h use of graft s and surgical flaps can increase salvat ion rat es in t hese pat ient s.1
Use of subint im al angioplast y for t he t reat m ent of occlusive at herosclerot ic lesions of t he lower lim bs was described for t he first t im e by Bolia.2 - 5 Subsequent publicat ions reaffirm ed t he
effect iveness of t his t echnique as an alt ernat ive t o infrainguinal revascularizat ion surgery.6 - 8 This art icle described a m inim ally invasive t echnique for t he t reat m ent of a pat ient wit h m ult iple com orbidit ies, crit ical lower lim b ischem ia and com plex infect ed wound of t he left foot .
Ca se r e por t
A 66- year- old fem ale pat ient wit h hypert ension, dyslipidem ia, diabet es m ellit us, heart failure, coronary disease, and ischem ic syndrom e of t he lower lim bs progressed wit h flogist ic signs in t he left foot associat ed wit h pain and fever. At adm it t ance t o t he em ergency room , presence of volum inous plant ar abscess was ident ified. The assessm ent perform ed by t he clinical t eam det erm ined surgical risk as I V according t o t he Am erican Societ y of Anest hesiology ( ASA I V) . On physical exam inat ion, t he pat ient had foot hyperem ia associat ed w it h volum inous plant ar m ass wit h fluct uat ion, in addit ion t o lym phangit is, ext ending unt il t he dist al t hird of t he t high, w it h palpable fem oral pulses, and absent poplit eal and dist al pulses. Art erial color - flow Duplex scan
showed presence of chronic segm ent al occlusion of t he superficial fem oral art ery in t he m iddle and dist al t hirds.
Aft er clinical st abilizat ion, choice was for endovascular revascularizat ion of t he left lower lim b using t he t echnique of subint im al angioplast y wit hout st ent ing or endograft ing, as described by Bolia et al.2 Art erial access was creat ed t hrough ant erograde punct ure of t he left fem oral art ery, using an 18G punct ure needle and insert ing a 7F sheat h according t o t he t echnique described by Seldinger. Art eriography was perform ed, confirm ing t he lesions described by t he Doppler ult rasound,
Over a 6- m ont h period, m ult iple debridem ent s were perform ed, and t here was change in wound aspect : t he init ially pale t issue was replaced by a granulat ion t issue. The wound m argins were t hen gradually approxim at ed unt il t he m uch expect ed epit helizat ion was achieved (Figure 5).
D iscu ssion
The t reat m ent of com plex wounds of t he diabet ic foot is a great challenge for vascular surgeons. The evolut ion shown by t his pat ient corroborat es t he high rat es of lim b salvat ion in series of subint im al angioplast y.9 - 1 1
report ed high com plicat ion rat es of surgical wounds.1 2 Puskas et al. report ed a 34% incidence of surgical wounds of t he lower lim bs subm it t ed t o saphenous vein st ripping for m yocardial
revascularizat ion.1 3
Subint im al angioplast y wit hout st ent ing has been widely approached in t he lit erat ure,1 - 1 1 and is corroborat ed by our case report .
Lower lim b revascularizat ion associat ed wit h int ensive care in diabet ic foot wounds provides m aj or benefit s for t hese pat ient s, especially st able wound coverage and preservat ion of walking abilit y; t herefore, it should always be considered before am put at ion. Thus, t he subint im al angioplast y t echnique is recom m ended as an alt ernat ive in pat ient s at high surgical risk w it h com plex wounds in t he lim bs.
Re fe r e n ce s
1. Verhelle NA, Lem aire V, Nelissen X, Vandam m e H, Heym ans O. Com bined reconst ruct ion of t he diabet ic foot including revascularizat ion and free- t issue t ransfer. J Reconst r Microsurg.
2004; 20: 511- 7.
2. Reekers JA, Bolia A. Percut aneous int ent ional ext ralum inal ( subint im al) recanalizat ion: how t o do it yourself. Eur J Radiol. 1998; 28: 192- 8.
3. Bolia A. Percut aneous int ent ional ext ralum inal ( subint im al) recanlisat ion of crural art eries. Eur J Radiol. 1998; 28: 199- 204.
4. Bolia A, Brennan J, Bell PR. Recanalisat ion of fem oro- poplit eal occlusions: im proving success rat e by subint im al recanalisat ion. Clin Radiol. 1989; 40: 325.
5. Bolia A, Miles KA, Brennan J, Bell PR. Percut aneous t ranslum inal angioplast y of occlusions of t he fem oral and poplit eal art eries by subint im al dissect ion. Cardiovasc I nt ervent Radiol. 1990; 13: 357-63.
6. London NJ, Srinivasan R, Naylor AR, et al. Subint im al angioplast y of fem oropoplit eal art ery occlusions: t he long- t erm result s. Eur J Vasc Surg. 1994; 8: 148- 55.
7. Laxdal E, Jenssen GL, Pedersen G, Aune S. Subint im al angioplast y as a t reat m ent of fem oropoplit eal art ery occlusions. Eur J Vasc Endovasc Surg. 2003; 25: 578- 82.
8. Treim an GS, Whit ing JH, Treim an RL, McNam ara RM, Ashrafi A. Treat m ent of lim b- t hreat ening ischem ia w it h percut aneous int ent ional ext ralum inal recanalizat ion: a prelim inary evaluat ion. J Vasc Surg. 2003; 38: 29- 35.
9. Lipsit z EC, Ohki T, Veit h FJ, et al. Does subint im al angioplast y have a role in t he t reat m ent of severe lower ext rem it y ischem ia?J Vasc Surg. 2003; 37: 386- 91.
10. Desgranges P, Boufi M, Lapeyre M, et al. Subint im al angioplast y: feasible and durable. Eur J Vasc Endovasc Surg. 2004; 28: 138- 41.
12. Hassen TA, Fitridge RA. Infra-inguinal revascularization surgical site infections: Australasian benchmark. ANZ J Surg. 2005;75:967-71.
13. Puskas JD, Wright CE, Miller PK, et al. A randomized trial of endoscopic versus open saphenous vein harvest in coronary bypass surgery. Ann Thorac Surg. 1999;68:1509-12.
Cor r e sponde nce :
Bernardo Massi€re
Dep. de Cirurgia Vascular e Endovascular – Centervasc-Rio Rua Sorocaba 464, 1‚ andar
CEP 22271-110 – Rio de Janeiro, RJ, Brazil Email: bmassiere@yahoo.com.br
No conflicts of interest declared concerning the publication of this case report.
