A Case of Chronic Limb-threatening Ischemia Treated with OPCAB after Distal Bypass Surgery

Abstract

Most patients with chronic limb-threatening ischemia (CLTI) also have diabetes mellitus and are undergoing dialysis; simultaneous coronary artery lesions are often present. We report the case of a 59-year-old woman with diabetes mellitus who had been receiving dialysis treatment for 9 years. She had a severe ulcer on her right toe, for which she underwent endovascular treatment at another hospital. However, the infection continued to worsen over the next 9 months and as a result, she was transferred to our facility. The infection spread to the middle of her foot and contained necrotic tissue. A preoperative angiogram revealed occluded arteries in bilateral lower legs and bifurcated coronary artery lesions, including the left main trunk. Immediate revascularization and necrotic tissue debridement was considered to be essential to avoid major amputation. As such, we first performed right distal bypass and debridement after endovascular treatment of the right superficial femoral artery, followed by off-pump coronary artery bypass surgery involving LITA-LAD, Ao-SVG-#12. Additional debridement of the right foot was performed at 19 days post-surgery. Subsequently, vacuum-assisted closure therapy was initiated and the patient underwent split-thickness skin grafting. The condition of the foot gradually improved and the patient was able to walk unaided. The patient did not develop angina and was discharged 57 days post-surgery. Therefore, combined treatment for CLTI demonstrated satisfactory results.