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Case Sharing: A case of CLTI with Free Flap Necrosis due to Repeated Distal Bypass Graft Occlusions that was Successfully Salvaged by Percutaneous DVA

Dr. Tomonari Takagi, General Takatsu Central Hospital

Case

Male in his 50s

Chief complaint

Loss of pulsation in the right distal bypass graft, pain at rest

Current medical history

In May 20XX, there was gangrene in the right 3rd and 4th toes, and endovascular treatment (EVT) was performed based on the diagnosis of critical limb ischemia (CLTI). However, the EVT to BTK failed and the wound did not heal, so a distal bypass was attempted in May of the following year, but an anastomosis at the distal posterior tibial artery was not possible due to severe calcification. Therefore, an anastomosis was hurriedly made to the dorsal cutaneous vein of the foot, and surgical DVA was performed.

In October of the same year, a TMA was performed, during which microvascular flap transfer grafting was performed using the distal bypass. The dorsal tibial vein to which the graft was anastomosed was ligated, the graft was anastomosed to the artery of the free skin valve, and the wound was allowed to heal.

In March and August of the following year, acute occlusion occured in distal bypass graft, and endovascular treatment was performed at another hospital. In November of the same year, the patient was rushed to our hospital due to loss of pulsation in the right distal bypass graft and pain at rest.

Medical history

21 years ago in 20XX: Maintenance dialysis due to end-stage renal failure

9 years before, 3 years before, and 2 years after 20XX: PCI due to diagnosis of angina pectoris

8 years before 20XX: Distal artery bypass for left CLTI

Year 20XX: EVT for right CLTI

The year after 20XX: Distal artery bypass and microvascular flap transfer grafting for right CLTI

Two years after 20XX: EVT for acute occlusion of left distal bypass graft

Life history

Smoking history: Ex smoker (10 cigarettes x 25 years)

Allergy to contrast media (redness)

Progress of distal bypass surgery In 20XX, an incision was made due to infection spreading to the s...

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