Endovascular Management of Complex Critical Limb Ischemia in a Non-Surgical Patient
This case focuses on an 85-year-old female with a history of coronary artery disease (CAD) status post myocardial infarction and ventricular fibrillation with subsequent implantable cardioverter-defibrillator (ICD), hypertension, hyperlipidemia, and severe peripheral arterial disease status post multiple failed right iliac angioplasty/bare-metal stenting procedures and subsequent right-to-left femoral-femoral bypass. The patient presents with several months of worsening left foot pain and a non-healing left fourth toe ulcer. Ankle brachial index (ABI) of the left lower extremity is 0.00, suggesting a diagnosis of Rutherford class V critical limb ischemia. Angiography reveals bilateral iliac occlusion. The fem-fem bypass graft is patent but is non-functional due to a lack of right iliac inflow. She is evaluated by vascular surgery and is turned down for further surgical treatment other than possible amputation. She is referred to the interventional cardiology clinic for possible complex endovascular options.
Which of the following is a reasonable approach for endovascular intervention?