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Multifocal atherosclerosis. When? What to do first? What is the treatment method?

Patient Y., 80 years old. BMI: 34.60 kg / m² Complaints: pain in the lower extremities when walking up to 30m. Numbness of the face, fingers of the left hand.

CTA: stenoses of both iliac arteries. Right superficial femoral artery occlusion and multiple tibial artery stenosis.
There is practically no deep and superficial femoral arteries on the left on angiography
absence of tibial arteries on angiography (no outflow pathways) part 1
absence of tibial arteries on angiography (no outflow pathways) part 2

Preoperative ultrasound examination of the carotid arteries revealed an increase in the linear blood flow velocity in the internal carotid artery of 320 cm / sec; therefore, a decision was made to perform a simultaneous angiography of the arteries of the lower extremities and brachiocephalic arteries.

internal carotid artery stenosis 75%

Our solution: сarotid endarterectomy under conduction anesthesia (without sedation, without intubation). In the absence of complications after carotid endarterectomy transit to hybrid surgery of PAD: iliac artery stenting + femoro-popliteal bypass grafting in situ left.

Distal anastomosis of the vein in situ with the popliteal artery.
Stenting of the right iliac artery

Thus, in an 80-year-old patient with a history of stroke, ischemia of both lower extremities, we managed to improve blood circulation in both lower extremities in different ways and to perform brain revascularization.