Vascular Team Approach in Dealing with Unstable Angina With ULMCA Disease, Bilateral Subclavian Stenosis and Limb Threatening Ischemia Dependent on Winslow’s Pathway
Presenter
Mariam S Baig, MD, Saint Louis University Hospital, Saint Louis, MO
Mariam S Baig, MD, Saint Louis University Hospital, Saint Louis, MO
Title:
Vascular Team Approach in dealing with Unstable Angina with ULMCA disease, Bilateral Subclavian Stenosis and Limb Threatening Ischemia dependent on Winslow’s pathway
Introduction:
Use of a multidisciplinary team approach is essential when considering revascularization and surgical risk in patients with complex vascular disease. We present a case of a patient with left main disease, infrarenal aortic occlusion with evidence of critical limb ischemia and collateral circulation from LIMA managed successfully by collaboration among interventional cardiologists, cardiac surgeons and vascular surgeons.
Clinical Case:
73-year-old male presented with Rutherford 4 lower extremity symptoms. Exam notable for pulseless lower extremities with delayed capillary refill. Ankle-brachial index of 0.45 (toe pressure 24 mmHg) right and 0.35 (toe pressure 17 mmHg) left. CT angiogram showed infrarenal aortic occlusion extending to bilateral external iliac arteries with CTO of right subclavian and severe stenosis of the left subclavian artery notable for a prominent Winslow’s pathway. Unstable angina (masked by lower extremity symptoms) identified during preoperative evaluation. EKG with normal sinus rhythm, no ST changes. Preserved ejection fraction on echocardiogram. Ultrasound guided access obtained in right radial. Right subclavian CTO was crossed using a support catheter and coronary guidewire. Coronary angiogram revealed calcified coronary arteries with 90% distal trifurcating LMCA, with a 70% ostial LAD, 80% ostial, 80% mid lesions in the left circumflex and a 70% lesion in the proximal ramus marginalis. 50% lesion identified in the mid RCA. SYNTAX score = 32. LIMA angiography showed patent vessel that extended distally to pelvis with anastomosis at level of left femoral artery providing collateral circulation to obstructed distal aorta. Vascular Team (vascular surgery, interventional cardiology and cardiac surgery) held family discussion. Cardiac surgery felt to be unsafe due to dependence on LIMA for limb viability. Decision made to perform ULMCA PCI without hemodynamic support. Using a right radial approach, trifurcation was wired and ostial LCx disease treated with laser atherectomy/PTCA. Distal LMCA lesion stented into the LAD with IVUS guided deployment of an everolimus eluting stent. Trifurcation stent re-crossed with further IVUS guided final simultaneous kissing balloon angioplasty- from LMCA into LAD and RM - with TIMI-3 flow in all 3 vessels. IVUS guided PTA and stent deployment performed in the RSCA with appearance of a 2+ right radial pulse at procedure termination. Post procedure angina improved, but increased at 3 months. Angiogram repeated as part of preoperative workup for aortobifemoral bypass. ULMCA stent and PTCA of LCx and RM were widely patent. 35 mmHg gradient noted across lesion in LSCA with widely patent stent in RSCA with large bilateral IMA. Winslow’s pathway noted on selective LIMA angiogram. Stable untreated lesion noted in mid-LCx. Patient cleared for aortobifemoral surgery.
Discussion:
This case is challenging given evidence of critical limb ischemia with collateral circulation via LIMA and bilateral subclavian stenosis. Thus, the patient’s complicated vascular disease also limits options for cardiopulmonary bypass during surgery. Routine use of a vascular team approach consisting of Vascular Surgery, Cardiac Surgery and Interventional Cardiology allows for prompt and comprehensive management of complex patients.