Critical limb ischaemia in a patient with a recent GI bleed and no vein conduit
A 74-year-old woman with type 2 diabetes and end-stage renal disease on haemodialysis presents with a non-healing forefoot ulcer and rest pain. ABI is 0.42 and toe pressure 28 mmHg. Duplex and CT show a 12 cm occlusion of the superficial femoral artery from the proximal to distal segment, with a patent popliteal artery and two infrapopliteal runoff vessels. She had a bleeding duodenal ulcer 3 weeks ago requiring transfusion; her cardiologist has stopped clopidogrel and wants her on aspirin alone. There is no suitable great saphenous vein (previous stripping), and she is a poor candidate for general anaesthesia. She is on warfarin for atrial fibrillation, INR 2.4. The vascular surgeon asks for an endovascular plan but is worried about stent-related bleeding risk. She has a dry gangrenous toe and a stable but deep ulcer.
1. What revascularisation strategy would you propose and why? Include access route and whether to use plain balloon, drug-coated balloon, atherectomy or stent.
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This is chronic limb-threatening ischaemia with tissue loss and a long SFA occlusion; revascularisation is limb-salvage treatment. Open bypass with prosthetic material in a patient with a recent GI bleed, no vein and high anaesthetic risk is unattractive. Endovascular treatment is first-line. Use an ipsilateral antegrade common femoral approach if the anatomy allows, because it gives better pushability for a 12 cm SFA occlusion; crossover access is an alternative but less favourable for long lesions.
There is no single ‘correct’ device. Plain balloon angioplasty avoids the need for DAPT and is the safest bleeding-risk option, but long SFA lesions frequently recoil or dissect, leading to bailout stenting. Drug-coated balloon improves patency but many protocols recommend DAPT, which is problematic after a recent GI bleed. Atherectomy is not clearly superior and adds cost and perforation risk. My plan: crossing and predilatation, then plain balloon with prolonged inflation; stent only for flow-limiting dissection or residual stenosis. If stenting is unavoidable, use the shortest stent and accept a modified antiplatelet plan after multidisciplinary discussion.
2. How would you manage anticoagulation and antiplatelet therapy around the procedure given the recent GI bleed and warfarin?
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The competing risks are stent thrombosis and recurrent GI bleeding. Continue aspirin because it is secondary prevention and stopping it adds thrombotic risk. Hold warfarin, check INR on the day and avoid bridging unless the atrial fibrillation stroke risk is very high and the bleeding risk has been reassessed; in this patient, recent ulcer bleeding argues against routine bridging. Perform the procedure with a target INR near normal and use radial or careful femoral access with closure.
If plain balloon alone is used, continue aspirin and restart warfarin once haemostasis is secure, usually after 24–48 hours. If a stent is placed, DAPT is standard, but after a recent GI bleed it is reasonable to use aspirin plus clopidogrel for the shortest acceptable duration (often 1 month for a bare-metal stent) with a proton-pump inhibitor, then clopidogrel alone or aspirin, depending on cardiology and GI input. If DAPT is felt absolutely contraindicated, aspirin alone with close surveillance is a defensible compromise, but document the shared decision.
3. What intraprocedural endpoints would you use to decide whether to stop after balloon angioplasty or proceed to stenting?
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After angioplasty, perform angiography and measure a pressure gradient if there is doubt. Acceptable endpoints are residual stenosis <30%, no flow-limiting dissection (grade C or worse), brisk flow into the popliteal and runoff vessels, and a mean pressure gradient <10 mmHg. Also assess recoil and whether the balloon required high pressure or multiple inflations. If there is a flow-limiting dissection, residual stenosis >30%, or a significant gradient, place a stent. If the vessel is widely patent with good flow, stop; a ‘provisional’ strategy avoids unnecessary metal and DAPT. Always treat inflow and outflow disease if present, and document the final angiographic result before sheath removal.