Department of Cardiology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
Date of Web Publication
Correspondence Address: Ramachandra Barik Department of Cardiology, Nizam's Institute of Medical Sciences, Hyderabad - 500 082, Telangana India
Source of Support: None, Conflict of Interest: None
A 70-year-old amputee, who was a known case of diabetes, hypertensive, and smoker presented with disabling ischemic symptoms and signs of gangrene in the stump of the left lower leg. He had undergone above knee amputation 2 months back for the gangrene of left foot with an ankle-brachial index (ABI) of 3. Computed tomography of infrarenal aorta and both the lower limbs arteries revealed total occlusion of common iliac artery, external iliac, and common femoral artery in the amputated leg. The occluded arterial segment was successfully opened percutaneously from left brachial approach. The message of this illustration is never ignore the exact extent of peripheral disease before amputation.
Although it is unusual to have atherosclerotic peripheral arterial disease (PAD) below 55 years, its prevalence increases sharply with age to affect ≈8-10% of individuals aged >65 years and ≈20% of individuals aged >80 years.  In the most severe form of PAD, patients suffer from critical limb ischemia manifested as rest pain and tissue necrosis. Timely revascularization significantly prevents or reduces morbidity, loss of limb, and mortality. The contemporary consensus agrees an attempt of endovascular revascularization should precede surgical revascularization irrespective of the extent of disease. ,, Despite low primary patency rate and need of repeat intervention, the secondary patency rate after reintervention is as good as surgery. 
A 70-year-old man who has known the case of diabetes mellitus, hypertensive, and smoker presented to us with impending ischemic gangrene of stump of the left lower leg. He had undergone above knee amputation just 2 months back somewhere else for PAD of left lower limb. His dreaded fear was whether doctor would again suggest him above thigh amputation! An accompanied computed tomography with three-dimensional (3D CT) reconstructions showed total occlusion of common iliac, external iliac, and common femoral arteries of left lower limb, i.e. TASC-2007 C.  Conventional angiogram showed mild atheromatous disease of infrarenal aorta and normal arteries in the right lower limb but complete occlusion of the left common iliac artery at the ostium with poor distal reformation at the carina of the left common femoral artery and profound femoris artery [Figure 1]a and Video 1]. Then total occlusion of left lower limb was successfully revascularized with Epic stent of size 10 cm × 8 mm (Epic Stent System) from left brachial approach [Figure 1]b and Video 2]. A cross over access via right femoral artery was used to profile the exact placement of the stent at the left aortoiliac junction. By the end of 3 months, after revascularization, the amputee had no symptoms or signs of ischemia. Doppler signals were almost normal in the amputated limb.
Figure 1: (a) Infrarenal aortogram through left brachial approach using 5Fr pigtail catheter showed total occlusion of the left common iliac artery from ostium without any apparent distal reformation. (b) Angiogram using Judkin's 5Fr guiding catheter from right femoral approach showed successful stenting of the left common iliac artery and external iliac artery
It is extremely important to evaluate the exact extent of disease (TASC-2007), comorbidities, and available approach sites to reach target lesion for angioplasty to choose among the revascularization strategies because PAD in diabetes, smoker, and advanced age is quite extensive, and affects multiple arterial territories. The conventional angiography is limited by improper visualization of the extent of disease because of nonselective angiogram, a limited number of views, and no 3D reconstructions. Therefore, 3D CT is almost always must with supportive tests for hemodynamic assessment. In cases, wherein revascularization fails along with optimum medical therapy (OMT), amputation is alternative. OMT and graduated exercise, which are initial steps to the process of rehabilitation, should immediately follow revascularization. Minor amputation like one or two toes are not big issues, but major amputation like limb loss woos different kinds of sufferings to the amputees. The lack of mobility, social isolation, lethargy, pain, sleep, and emotional disturbance become more than controls (P < 0.001).  The overall quality of life following lower limb amputation for PAD is poor, but much of this is secondary to restricted mobility. It has been experience that sometimes the extent of PAD progress very fast like CAD in the arterial segments with mild diseases with or without previous revascularization and even in the amputated stump.  In our case, there may be two possible reasons for so significant lesion in the amputated limb. The first is the extent of disease may be missed outside, or there was very rapid progression disease because of subacute presentation. Therefore, a critical initial evaluation followed regular follow-up with support of functional and imaging modalities are must with follow-up for symptoms and signs. An adequate revascularization is clinically translated as significant improvement in ischemic symptoms and healing. Otherwise, too much meddling with diseased arteries without relief of ischemia is similar to missing the forest for the trees.  In other hand, too much worry about symptoms and sign may overlook the true extent of underlying disease (TASC 2007) and may mislead to amputation like missing the trees in caring the forest. After 3 months, amputated limb healed without ischemic symptoms or signs: The lonely life and ongoing ischemia in the amputated limb further deteriorates the quality of life. Both the trees and forest were restored in the end but in an amputee was a unique story of revascularization in PADs.
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