Endovascular treatment of a complex case of ischemic diabetic foot syndrome in a chronic kidney disease patient

This case presents a 68-year old dialysis patient with an ischemic diabetic foot. In this video, you will learn about:
(1) the anatomic challenges of diabetic foot syndrome
(2) the decision making in dialysis patients
(3) tips and tricks to cross chronic total occlusions (CTOs)
(4) how to treat the infrapoppliteal vessels and finally
(5) how to interpret the intraoperative angiographic images.


    Thank you Dr. Farraresi for the presentation. Please enlighten me with regard to the following questions: 1) were you able with the CO2-technique to have get a roadmap route during your procedure? 2) I understood you were very keen with the advancing and crossing the 0,018”-wire intraluminally based solely on the calcification landmarks of the SFA but does it suffice? I mean, can we be so sure about the proper route of the wire? What if it takes the subintimal plane at a certain point of the passage? Wouldn’t a roadmap help to stay in the intraluminal task? 3) would you of consider a prophylactic use of stent in such a high risk for reccurence patient after the SFA revanalization or we follow the “leave-nothing-behind”approach? 4) regarding the PTA spasm, would you consider delivering a dose os vasodilating drug locally via eg. a long sheath and when would you consider that? 5) as I notice, a short proximal segment of the SFA was considerably stenosed; I personally had a recent case of mine where the proximal passage of a 5fr sheath through such SFA proximal segment led to inadvertent serious compromization of the femoral bifurcation and proximal SFA, leading to open conversion under local anesthesia, limited endarterectomy with GSV patch restoration. Would you consider the contralateral over-the-bifurcation approach as a safer technique?
    Many thanks!

    Excuse the typo error: I meant a 6F sheath through such SFA proximal segment in question 5…

    Dr Roberto Ferraresi
    June 14, 2018

    1) I use roadmap very rarely. I didn’t try with CO2, however I think it could be possible
    2) Endoluminal or subintimal have similar outcomes, however in my experience, in case of diffuse calcification like in this case, to maintain an endoluminal route is better, because the two exit and re-entry points are difficult to manage and often require stenting.
    3) My first approach is the “leaving nothing behind stategy”. After DCB treatment, if I consider the result acceptable, I don’t use stent. Obviously, at least in part, this approach is due to economical reason.
    4) Spasm is due to our maneuvers, and is generally resistant to drugs. I always inject TNG intra-arterial or Verapamil. If I want to inject drugs locally I use the OTW balloon (wire hole!) and not long sheaths.
    5) There is a paper by Flavio Airoldi describing the omolateral approach in treating ostial SFA lesion: he stated that we need at least 2 cm to be able to do a proper treatment. In the vast majority of the cases I maintain an antegrade 4F femoral approach. I shift to contralateral only in case of ostial SFA lesion and high bifurcation
    Ciao, Roberto

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