Successful Cases of Combined Treatment for WIfI Clinical Stage 4 Chronic Limb-Threatening Ischemia Using Popliteal-to-Distal Bypass, Minor Amputation, Debridement, and Rheocarna Therapy in Hemodialysis Patients: A Case Series

Chronic limb-threatening ischemia (CLTI) is a severe form of lower extremity artery disease. CLTI is an umbrella term for conditions in which the lower limb is threatened by ischemia, tissue defects, neural disorders, or infection. In Japan, CLTI primarily affects patients with diabetes and those on hemodialysis. The severity of CLTI is assessed using the Wound, Ischemia, and foot Infection (WIfI) classification. CLTI needs multidisciplinary therapy. Rheocarna is a novel direct hemoperfusion device and can adsorb low-density lipoprotein (LDL) cholesterol and fibrinogen, thereby improving hemorheology. However, reports describing its use after distal bypass surgery are limited. In this report, we present three initial cases of successful combined treatment for WIfI clinical stage 4 CLTI in patients undergoing hemodialysis, including distal bypass, minor amputation, debridement, and Rheocarna therapy. Case 1 is a 67-year-old man with CLTI in the left foot. Endovascular therapy (EVT) failed to revascularize the anterior tibial artery (ATA). Necrosis of the left fifth toe progressed, and the ulcerative purulent wound tested positive for Pseudomonas aeruginosa (W3I3fI1; stage 4). A left below-knee popliteal-to-dorsal artery in situ bypass was performed, and the necrotic fifth toe was amputated, followed by maintenance debridement. Rheocarna therapy was initiated on postoperative day (POD) 13 (a nonhemodialysis day following the fifth postoperative dialysis) and administered twice weekly for a total of 12 sessions. Three months after surgery, the wound healed. Case 2 is a 71-year-old man with CLTI and necrosis of the left fourth and fifth toes. EVT failed to revascularize the chronic total occlusion (CTO) at the distal ATA. The ulcerative purulent wound tested positive for Escherichia coli (W3I2fI3; stage 4). A left below-knee popliteal-to-posterior tibial artery (PTA) in situ bypass was performed, and the necrotic third and fifth toes were amputated. Maintenance debridement with negative pressure wound therapy was performed. Rheocarna therapy was initiated on POD 7 (a nonhemodialysis day following the third postoperative dialysis) and administered twice weekly for a total of eight sessions. Three months after surgery, the wound healed. Case 3 is a 79-year-old man with CLTI and necrosis of the right first and fifth toes. EVT failed to revascularize the CTO at the distal ATA and PTA. Necrosis worsened, complicated by cellulitis, and the purulent wound tested positive for Staphylococcus aureus (W2I3fI3; stage 4). A right below-knee popliteal-to-dorsal artery in situ bypass was performed, and the necrotic first and fifth toes were amputated, followed by maintenance debridement. Rheocarna therapy was initiated on POD 9 (a nonhemodialysis day following the fourth postoperative dialysis) and administered twice weekly for a total of nine sessions. Three months after surgery, the wound healed. Rheocarna therapy may reduce postoperative fibrinogen, LDL cholesterol and lipoprotein(a), improving microcirculation and avoiding bypass graft failure, surgical site infection and delayed wound healing. Given the limited reports on the use of Rheocarna after distal bypass, it is important to accumulate more cases and long-term outcome data. Further multicenter studies or registry data are needed to validate the optimal timing and frequency of Rheocarna therapy.