AB CD E


F GH I J


Figure 1. Left lower extremity angiogram performed from right common femoral artery access reveals 80% left external iliac artery stenosis (blue arrow) (A), which resolved after angioplasty and self-expanding stent placement (star) (B). Flush occlusion of the left SFA (black arrow) (C) with reconstitution at the level of the adductor canal (D) (black arrowhead) was then addressed, with successful crossing via antegrade up- and-over and retrograde pedal access (E), followed by orbital atherectomy, drug-coated balloon angioplasty (F), and spot drug-eluting stent placement. Final angiographic images (G–J) revealed rapid blood flow to the foot with filling of the deep pedal arch, but with persistent non-filling of the pedal-plantar loop due to chronic occlusion of the left dorsalis pedis and left lateral plantar arteries.


Diabetes


• Elevated glycosylated hemoglobin levels (HgA1c) are associated with poor wound healing, higher amputation rates11


• Recommendations: • Aggressive HgA1c monitoring • Endocrinological consultation • Low-sugar diet


Medical management of concurrent lipid and hypertension management based on the ACC-AHA guidelines (a class 1a recommendation in CLI patients) is also crucial to promoting healing.12


Medical optimization is


crucial in creating the optimal wound healing environment. However, in-depth review of the complete medical management of CLI is beyond the scope of this article.


Once proper medical management has been initiated and the patient condition is deemed amenable to intervention, we proceed with a diagnostic angiogram and intervention with the goal of restoring angiographosomal or wound-related artery-directed13,14


blood flow to the


wound, with specific techniques being beyond the scope of this article. Our surgical colleagues may use blood at the site of surgical wound debridement as a marker for interventional success. Traditional benchmarks for successful reperfusion after lower extremity arterial revascularization include angiographic luminal gain, contrast washout and wound blush.15


However, we have seen


discordant results at the microvascular level with wound healing failure


despite advances in “technically successful” below-the-knee, ankle and even pedal loop reconstructions.


Several emerging technologies can be useful in assessing distal perfusion, facilitating the decision on whether to proceed with debridement, amputation or further revascularization. One such technology is near-infrared fluorescence angiography (NIFA), which uses indocyanine green (ICG) dye to assess a semiquantitative measurement of dermal and subdermal microcirculation.16


(See following


case.) In addition to immediate postrevascularization optical feedback, early research has demonstrated the accuracy of quantitative ICG analysis after intervention when compared to standard perfusion measures, such as ankle brachial indices (ABIs).17


This is


especially helpful when ABI accuracy is limited by noncompressible, calcified, diseased vessels, present in many of our patients with poorly controlled diabetes and end-stage renal disease.


Another perfusion assessment that has proved useful in analyzing PAD is hyperspectral tissue oxygenation measurement (HTOM), as seen in the handheld HyperViewTM


device.


It measures oxygen saturation, oxyhemoglobin and deoxyhemoglobin levels of the superficial subcutaneous tissue, creating color-coded anatomic images based on tissue oxygenation, providing a measure of perfusion. Implementing perfusion analysis in our multidisciplinary practice has helped us optimize patient outcomes by


determining periwound perfusion as a surrogate for tissue viability.


Case illustration and conclusion 70-year-old female with history of hyperlipidemia, hypertension, 60 pack-year former smoker, with PAD/ CLI referred for evaluation of worsening severe bilateral ulcerations on the feet for several months. Physical exam demonstrated severe gangrene of the 2nd left toe (Fig. 2) compatible with Rutherford 6 and severe gangrene at the lateral plantar aspect of the left 1st digit (Fig. 2) compatible with Rutherford 5 classification. After the patient was optimized for wound healing, we proceeded with angiography with collaboration with the podiatry service with plan for follow-up debridement.


Left lower extremity angiogram demonstrated 80 percent stenosis of the entire left external iliac artery (EIA), flush occlusion of the left SFA with reconstitution at the level of the adductor canal, and focal left P2 popliteal artery occlusion with two- vessel infrapopliteal runoff via the left posterior tibial and peroneal arteries. Staged revascularization was successful with angioplasty and self-expanding stent placement resolving the left external iliac artery stenosis (Fig. 1).


Following this, an antegrade-retrograde approach was used to recanalize the left anterior tibial artery, P2 popliteal artery occlusion and flush SFA occlusion, with orbital atherectomy, angioplasty/drug-coated balloon angioplasty and drug-eluting stent placement (Fig. 1). Final angiographic images revealed rapid blood flow


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