Title : Heart first, then the limb: Staged revascularization in chronic limb threatening ischemia with symptomatic multivessel coronary artery disease

Background: Chronic limb-threatening ischemia (CLTI) frequently coexists with coronary artery disease (CAD), and the rate of cardiovascular and limb events rises with the number of affected arterial beds.1,2 When both territories require revascularization, deciding which to treat first, and how, is rarely straightforward.

Case Presentation: A 63-year-old man with type 2 diabetes presented with dyspnea, leg edema, angina, and infected left foot ulcers that had continued to enlarge despite surgical debridement at another hospital (ankle–brachial index 0.5; Wound, Ischemia, and foot Infection [WIfI] W2I2fI1). Echocardiography showed a left ventricular ejection fraction of 37% with regional wall-motion abnormalities. He also had anemia (hemoglobin 8.9 g/dL) and impaired renal function (eGFR 56 mL/min/1.73 m²). Coronary angiography revealed three-vessel disease (SYNTAX score 21), and the left anterior descending artery (LAD) was treated by percutaneous coronary intervention (PCI) with two drug-eluting stents; staged PCI of the remaining vessels was planned to limit contrast exposure. Six weeks later, after clinical optimization, lower-limb arteriography showed multifocal 80–95% stenoses of the anterior tibial and peroneal arteries with distal peroneal occlusion. Balloon angioplasty of both vessels restored flow to the foot, and at one month the ulcers had decreased in size with partial reepithelialization.

Discussion: Failure of the ulcer to heal after debridement was most likely due to untreated infrapopliteal occlusive disease, as wound care alone cannot succeed without adequate perfusion.2 Coronary revascularization was performed first because angina and heart failure were the presenting problems and the LAD was severely diseased from its proximal segment. PCI rather than coronary artery bypass grafting was chosen because anatomical complexity was low and the local waiting time for surgery was approximately one year. Because impaired renal function, diabetes, heart failure, and anemia all increased the risk of contrast-associated kidney injury, PCI was limited to the LAD, which supplies the largest myocardial territory. Endovascular therapy was chosen for infrapopliteal disease because heart failure, renal impairment, and anemia increased the risk of open surgery. This is consistent with BASIL2, in which a vein bypass-first strategy was associated with a higher risk of major amputation or death than a best endovascular treatment-first strategy.4 Current guidelines recommend comprehensive cardiovascular assessment and risk reduction in patients with CLTI.2,3

Conclusion: A diabetic foot ulcer that fails to heal after debridement should prompt assessment for limb ischemia and coexisting CAD. In patients with CLTI and multivessel CAD, a staged strategy that treats the coronary disease first and the limb endovascularly, with contrast-sparing planning, may achieve limb salvage while addressing the dominant cardiovascular risk. Longer follow-up is needed to confirm durable wound healing and limb outcomes.

Keywords: chronic limb-threatening ischemia; polyvascular disease; multivessel coronary artery disease; below-the-knee angioplasty; diabetic foot ulcer

Dr. Jeprin Ruru is an internist and a fourth-semester fellow in the Cardiovascular Subspecialty Program of Internal Medicine at the Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia. He earned his medical degree from Universitas Diponegoro in 2010 and completed specialist training in internal medicine at the same university in 2018. His current training covers the diagnosis and management of cardiovascular disease within internal medicine.