Restoring Flow in Multi-Vessel Disease
Ted Gifford, MD
Hartford HealthCare
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This is a really great example of how the Serranator can be used to treat multiple different sizes and multiple different locations of tibial vessels. This is a 65 year old gentleman who presented with a history of poorly controlled diabetes, chronic kidney disease and gangrene with active cellulitis associated with his first toe down to the base of the first metatarsal.
He had been non-compliant with medical therapy for some time, and as a result, he had gone on to have a pretty significant tibial disease. He had no pedal pulses present on physical examination, and only weak Doppler signals in the DP and PT distribution. If you look at his below the knee angiogram, you see that if the proximal tibial vessels the anterior tibial arteries occluded, the peroneal artery has multiple tandem high grade stenoses and the posterior tibial artery proximately is patent although likely undersized.
Going down into the foot, you can see that the peroneal gives off some collaterals with a late filling of the plantar artery, but that otherwise the posterior tibial artery and the anterior tibial artery are occluded. We went in with the Serranator, and we were able to successfully achieve in line two, or flow by treating the PT as well as the peroneal artery for the PT. We pre-dilated the distal posterior to the artery and common plantar artery using a 2 millimeter balloon, followed by 2.5 by 120 millimeter Serranator balloon angioplasty at less than nominal pressures. You can see on the completion angiogram result, restoration of flow and previously occluded distal PT with good runoff flow to the plantar vessels and no evidence of significant or flow limiting dissection.
Going up to the peroneal artery. We treated this without pre-dilation, with a single 3 millimeter by 120 millimeter Serranator balloon across these tandem stenosis. Again, this was inflated to less than nominal pressure and we achieved complete expansion of the balloon with a completion angiogram. This area shows a really robust peroneal artery at this point with no evidence of dissection and great flow again preserved distally.
This case was able to be completed in less than an hour, and the patient went on to have a first toe amputation, which he subsequently healed without issue. I think to me this really underscores the value added by using Serration technology. This allowed us to deliver a really robust flow to this patient at a time when they needed the ability to heal their wound, and when they might have had some other contraindications to performing a more aggressive bypass, such as their medical risk factors, as well as the active infection present at their toe.
