When a Patient Presents with an Ulcer, Take a Careful History

A 56-year-old transgender female presents with a 3-month history of a 4 cm x 5 cm, non-healing ulcer on the dorsum of the foot. She had previously been diagnosed as having an idiopathic cardiomyopathy. She has had a history of hyperlipidemia and tobacco abuse. When eliciting a history, the patient admits to classic claudication bilaterally. We were asked to see the patient because of the question of possible cardiac clearance prior to amputation. Instead we decided to perform angiography.

Figure 1. Angiography reveals 100% occlusion of the SFA with a long stenosis as the vessel enters the adductor canal.

 

 

 

Figure 2. Using a contralateral approach, a 6 Fr Wildcat catheter (Avinger) easily crossed the total occlusion.

 

 

 

Figure 3. Illustration of further passage of the Wildcat catheter into the relatively normal appearing SFA – popliteal.

 

 

 

Figure 4. We further debulked with the .9 mm laser (Spectranetics).

 

 

 

Figure 5. Final result after inflation with a 2 cm x 6 mm AngioScore balloon reveals an excellent result. The patient had 3-vessel run off to the foot and one week following the procedure is already noticing an improvement in wound healing.

 

 

Conclusion

When the clinical history suggests that the patient has peripheral vascular disease, it is always imperative to perform angiography with the possibility of improving peripheral flow. I suspect this woman’s cardiomyopathy may in fact be ischemic. This will be further evaluated after her wound has healed.

Coauthors: Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI and Karen L. Waters, MS, FNP-C

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When a Patient Presents with an Ulcer, Take a Careful History

A 56-year-old transgender female presents with a 3-month history of a 4 cm x 5 cm, non-healing ulcer on the dorsum of the foot. She had previously been diagnosed as having an idiopathic cardiomyopathy. She has had a history of hyperlipidemia and tobacco abuse. When eliciting a history, the patient admits to classic claudication bilaterally. We were asked to see the patient because of the question of possible cardiac clearance prior to amputation. Instead we decided to perform angiography.

Figure 1. Angiography reveals 100% occlusion of the SFA with a long stenosis as the vessel enters the adductor canal.

 

 

 

Figure 2. Using a contralateral approach, a 6 Fr Wildcat catheter (Avinger) easily crossed the total occlusion.

 

 

 

Figure 3. Illustration of further passage of the Wildcat catheter into the relatively normal appearing SFA – popliteal.

 

 

 

Figure 4. We further debulked with the .9 mm laser (Spectranetics).

 

 

 

Figure 5. Final result after inflation with a 2 cm x 6 mm AngioScore balloon reveals an excellent result. The patient had 3-vessel run off to the foot and one week following the procedure is already noticing an improvement in wound healing.

 

 

Conclusion

When the clinical history suggests that the patient has peripheral vascular disease, it is always imperative to perform angiography with the possibility of improving peripheral flow. I suspect this woman’s cardiomyopathy may in fact be ischemic. This will be further evaluated after her wound has healed.

Coauthors: Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI and Karen L. Waters, MS, FNP-C

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