Multidisciplinary Cardiovascular Treatment Saves Limb

UCSF Center for Limb Preservation

January 16, 2010

Bicknell Ramsay — a 74-year-old retired engineer who lives a fully active life — was concerned that a wound on his foot would not heal. Having volunteered for a clinical study on peripheral artery disease (PAD), he described the wound to the principal investigator, UCSF nurse practitioner Roberta Oka, R.N., DNSc. She referred Ramsay to Michael S. Conte, M.D., (pictured at right on left), Chief of Vascular and Endovascular Surgery at UCSF Medical Center.

By then, the wound exceeded two centimeters and was enlarging. After an ankle-brachial index test found only 30 percent of normal perfusion in Ramsay's legs, Conte suspected limb-threatening ischemia — and worse. "He didn't have any of the traditional risk factors, but he was describing episodes of chest pain and shortness of breath," says Conte.

Consequently, Conte had Ramsay's legs imaged and called in cardiologist Yerem Yeghiazarians, M.D., co-director of the UCSF Adult Cardiac Catheterization Laboratory. Catheterization revealed the extent of coronary artery disease (CAD) — all the main arteries in Ramsay's heart were more than 90 percent blocked.

"He was not on aggressive medical therapy for his atherosclerotic condition," says Yeghiazarians, who immediately prescribed antiplatelet and cholesterol-lowering medications, as well as a beta blocker.

Anxious to save Ramsay's leg and prevent a cardiac event, Conte and Yeghiazarians called in Scot Merrick, M.D., Chief of Adult Cardiothoracic Surgery at UCSF. The three determined that while Ramsay's anatomy was not favorable for stenting, Merrick could safely perform a quadruple coronary artery bypass graft (CABG). If successful, Conte could then complete a leg bypass.

Complications mount

As Merrick began the CABG procedure, he found Ramsay's coronary arteries so compromised that the best option was to bypass only the two main arteries. One bypass had to be done with an artificial graft because Ramsay did not have adequate veins to be used as bypass conduits. Nevertheless, the procedure eliminated Ramsay's cardiac symptoms, enabling the leg bypass. This too had its challenges because there were no good veins in Ramsay's legs; Conte successfully constructed the bypass with veins from Ramsay's arms.

Postsurgery, Conte and Yeghiazarians followed Ramsay very closely. Unfortunately, as the surgical wounds in his leg healed, Ramsay's cardiac symptoms reappeared.

"The artificial conduit had completely shut down," says Yeghiazarians. Because Ramsay was a poor candidate for a second heart bypass, Yeghiazarians then used stents to revascularize all of the arteries on the left side of Ramsay's heart. Over the next year, Conte and Yeghiazarians continued to follow their patient carefully, with Conte performing a minor revision to the leg bypass to clear scar tissue.

A life restored

More than a year out from all three procedures, though Ramsay still has occasional pains, he is doing much better and the wound on his foot is completely healed. He describes daily walks, all of the activities of normal life, and says, "I am doing well."

"It required complicated technical procedures, and close surveillance and collaboration from all three groups, but the result is a man who did not have to sacrifice his leg — and who has his life back," says Conte.