Durable 12-month Outcome with Serranator

Nicholas Petruzzi, MD

AMI Vascular Institute

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  So I'm going to present a case where we've used Serranator and it was game changing in the results. And I think it's a good example of how unique this technology is. So this is a 70 year old male. He presented to my practice with Rutherford Category 5, chronic limb threatening ischemia actually of both lower extremities, Both forefeet had extensive gangrenous changes present. He was actually post deep venous arterialization of the right forefoot, followed by trans metatarsal amputation and subsequent healing. He presented for regionalization plantar arch recanalization tibial peroneal recanalization of the left lower extremity in order to improve perfusion and follow that, hopefully, with trans metatarsal amputation. 

  These are two shots from digital subtraction angiogram of his left lower extremity. This shows extensive tibial peroneal occlusive disease with extensive plantar arch occlusive disease. The posterior tibial and the peroneal arteries occlude above the ankle. The anterior tibial artery is heavily calcified, with multiple segmental occlusions. The dorsal pedis is occluded again, as well as the deep plantar arch is occluded. These are two images from my initial intervention. I crossed the lesion, I was able to wire into the deep plantar arch, and I followed this with orbital atherectomy in order to modify the plaque, and I followed this with prolonged balloon angioplasty. 

  This DSA image shows the outcome from that intervention. I was pleased with the results. We had nice in-line flow through the anterior tibial artery into the dorsal pedis.

  Following that intervention, the patient underwent successful trans metatarsal amputation. These are images from his initial one month follow up after the angiogram and after trans metatarsal amputation. 

  This slide shows his surveillance duplex at four weeks post orbital atherectomy and angioplasty. We could see that we have strong upstroke and a nice multiphase wave form in the dorsal pedis.

  The patient initially was healing well and we were pleased with the results. However, at three months he started to develop some breakdown at the lateral and medial margins of his trans metatarsal amputation site. At that point, he was scheduled for surveillance duplex of the left lower extremity at the three months surveillance duplex, it was noted that he had a repeat occlusion recoil of the dorsal pedis.

  There's now mono aphasic waveforms and multiple areas of occlusion in the dorsalis pedis. Based on this finding, in order to help further promote healing and hopefully limb salvage, we repeated the angiogram. The repeat angiogram again shows recoil, restenosis in multiple areas of the distal and tibial artery, as well as the dorsalis pedis and plantar arch.

  Given his failure of initial orbital atherectomy and Plain old balloon angioplasty, I wanted to do something different in order to maximize the chance we could get this to heal. So what I did was I recanalized the occlusion of the anterior tibial and dorsalis pedis. I was able to wire back through the planter arch, and in this instance I employed Serranator technology.

  I performed Serranator angioplasty on the dorsalis pedis and the distal anterior tibial artery. You can see on this post DSR image that we had nice expansion and nice opening of the tibial and dorsal pedis arteries. This is an image of his duplex six months later after that intervention, you could see that there's still patent dorsalis pedis. The final image represent his trans metatarsal amputation site three months after that repeat angiogram using Serranator technology.

  It's now been almost a year since that repeat intervention. The patient clinically is fine. He has fully healed trans metatarsal amputation site and the dorsalis pedis and tibial arteries remain patent. So in summary, this is a patient who had early recoil and restenosis of below the knee and below the ankle disease. Following repeat angiography and repeat intervention using Serranator technology, we were able to achieve a durable clinical result for the patient.