A Case of Advanced Peripheral Artery Disease with Advanced Coronary Artery Disease-A Case Report

Objective: This case report describes a rare presentation of triple-vessel coronary artery disease (3 CAD) co-existing with advanced peripheral arterial disease (PAD) in a 65-year-old patient, focusing on the challenges in diagnosis and management.

Methods: A 65-year-old patient presented with retrosternal chest pain. A thorough clinical examination, electrocardiography (ECG), and additional diagnostic tests revealed STEMI. Coronary angiography confirmed advanced PAD alongside triple-vessel coronary artery disease (CAD). The patient was advised to undergo coronary artery bypass grafting (CABG), and a full-body aortogram was conducted to further assess the extent of PAD.

Results: Significant blockages were identified in major peripheral arteries, including the right brachial artery and both femoral arteries, along with three major coronary arteries: the right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LCX).

Conclusion: This case highlights the importance of a multidisciplinary approach in managing complex cases involving both advanced CAD and advanced PAD. Early and coordinated interventions can significantly improve patient outcomes in these high-risk situations.

Atherosclerosis, the thickening and stiffening of arteries due to build-up of plaque in the arterial walls, is characterized as a slow and progressive systemic inflammatory disease. It leads to stenotic lesions, resulting in ischemia and hypoxia to the vital organs and extremities [2]. Conditions like Peripheral Artery Disease (PAD), coronary artery disease (CAD), Carotid Artery Stenosis (CAS), and Abdominal Aortic Aneurysm (AAA) are the manifestations of this, due to its systemic nature [2] Both PAD & CAD, being the major consequence of atherosclerosis, have increased mortality and morbidity rate [1,3]. Common sites of atherosclerotic plaques causing PAD include Abdominal aorta, Iliac arteries, and femoral arteries leading to ischemia of the distal limbs and characteristic claudication [5]. PAD rarely advances to severe stages, but when it does, it can lead to gangrene or necessitate amputation of extremities. Studies show that patients with Advanced PAD have increased risk for Left Main or Triple-Vessel Arterial Disease [1,3], as both share like pathogenesis and risk factors [1].

PAD often exists asymptomatically with CAD [4] and patients present primarily with cardiovascular symptoms. The co-existence of Advanced-PAD with Triple-vessel or Left Main coronary artery disease is a rare clinical occurrence which poses a challenge to the clinical diagnosis and therapy. Advanced stages of PAD are often associated with multivessel CAD. A study indicated that 10% of all patients with PAD Fontaine IV showed 3-vessel CAD with the prevalence of multivessel CAD increased in advanced PAD patients [1]. In this report, we present a case of a 60-year-old male with retrosternal chest discomfort. Upon ECG investigation, acute ST elevation myocardial infarction (STEMI) was diagnosed. Further investigation revealed advanced PAD with 3-vessel CAD, resulting from multiple failed angiography attempts (discussed later). Advanced PAD with 3-vessel CAD coexisting together makes this case particularly unique, with limited literature available on such cases.

Case History and Examination

A 60-year-old male patient, with a known case of Hypertension and Diabetes Mellitus for the past 10 years on prescribed Antihypertensives and Anti Diabetic medications, presented to the ER of a public hospital with the complaint of chest pain for the past 5 hours. The pain was gradual in onset, piercing in nature, radiating to the left arm and shoulder associated with perspiration, palpitations, discomfort and SOB at rest. The pain was exacerbated on exertion with no relieving factors. The severity of pain was very high, rating it 8 out of 10 on the pain scale, with 10 being the most severe. The patient also reported pain in upper and lower limbs on exertion. On general physical examination, the patient had a normal build, with a pale face, showing no signs of anaemia and was lying in discomfort, agonising in pain. Upon arrival, his vitals were administered; Blood Pressure 170/100 mmHg, the pulse rate was 82 beats/min, respiratory rate was normal at 15 breaths/min, he was afebrile with normal Oxygen saturation 98% at room temperature and Glasgow Coma Scale E4V5M6. On a respiratory examination, the chest was clear with normal bilateral air entry, no added sounds. Abdominal examination revealed soft and non-tender abdomen with no abnormal peristaltic movements or sounds. Patient seemed agitated and anxious due to severe chest pain but was conscious and oriented to place and time. 

Case Investigation, Diagnosis & Treatment

The patient presented with symptoms of retrosternal chest discomfort, necessitating an Electrocardiogram (ECG) and various laboratory tests. The 12 lead ECG done in ER showed ST segment elevation in V1-V6, confirming the diagnosis of acute anterior wall STEMI shown in Figure 1. Laboratory tests were carried out, their results are shown in Table 1.

Figure 1: Electrocardiogram

Table 1: Lab test values of patient

An echocardiogram was performed, which showed Normal sized LV severely reduced function with SWMA & Normal RV size and function. Given these findings, STEMI was diagnosed, and coronary angiography was recommended for further findings. Upon the patient’s arrival at ER, the emergency protocol was promptly initiated. The patient received Non enteric Aspirin 300 mg, Clopidogrel 300 mg, and unfractionated Heparin, before undergoing coronary angiography. Coronary Angiography was performed, using the right radial artery approach with a 6 French sheath. However, due to severe stenosis in the right brachial artery, the attempt to advance the catheter was unsuccessful. Alternative Access Sites were then approached; the procedure was then redirected to the right femoral artery. Upon examination, it was found to be completely occluded, preventing further access. The left femoral artery was then evaluated. Although it was more accessible, it was also found to be significantly stenosed, complicating access.

Successful access was achieved via the left radial artery. This approach allowed for successful catheter placement and completion of the coronary angiography. Coronary angiography revealed a 100% occlusion in the upper segment of the right coronary artery (RCA), with faint collaterals from the left coronary system. The left main coronary artery, which contributes to major heart’s blood supply, displayed distal tapering consistent with atherosclerotic changes while the left anterior descending artery (LAD) was noted to have a significant ulcerated plaque in the proximal segment. Additionally, the left circumflex artery (LCX) showed significant stenosis of approximately 80%. Figure 2, 3 & 4 illustrate the blockage in the vessels mentioned above.

Figure 2: Right Coronary Artery

Figure 3: Left Anterior Descending Artery

Figure 4: Left Circumflex and Left Main Artery

The angiographic findings confirmed the presence of three-vessel coronary artery disease (CAD); defined as the blockage of >70% in the three major vessels of heart; in conjunction with advanced peripheral artery disease (PAD), characterized by stenosis in major peripheral vessels including the right brachial artery and both the right and left femoral arteries. Since LAD was patent with established flow and the patient was pain free at the time of angiography, coronary artery bypass grafting (CABG) was recommended as the appropriate treatment strategy. Aortogram of infra-renal & lower limbs was planned for further investigation of PAD.

The coexistence of three-vessel coronary artery disease (CAD) and advanced peripheral arterial disease (PAD) presents a unique and challenging clinical scenario. This case report highlights the complexities involved in managing such patients, particularly when standard angiographic approaches fail due to severe PAD. The association between CAD and PAD is well-documented. Approximately 42% of patients with CAD also have PAD [7]. This dual pathology significantly increases the risk of adverse cardiovascular events and complicates both diagnostic and therapeutic procedures. For instance, a case report from the Henry Ford Hospital described a patient with severe PAD and CAD, where standard angiographic approaches were also challenging [8]. Another report highlighted the increased prevalence of myocardial infarction in patients with PAD, emphasizing the need for careful management [7, 9]. This case highlights the challenges of managing patients with both CAD and advanced PAD. The difficulties experienced during angiography underscore the need for multiple access strategies and flexibility when dealing with advanced PAD. The presence of PAD in patients with CAD often indicates more extensive coronary disease, as seen in this case. PAD is associated with a higher prevalence of left main CAD or complex CAD, which can be quantified by a high SYNTAX score [7]. This association underscores the need for comprehensive cardiovascular assessment and a multidisciplinary approach to management. 

Despite significant stenosis in major vessels due to PAD, the patient’s distal limbs exhibited no major clinical signs such as diminished pulse, cyanosis, or numbness. This is a proof of the remarkable physiological process of collateralization which highlights the adaptive nature of the vascular system in chronic PAD and the importance of collateral circulation in preserving limb function. The decision to proceed with CABG was appropriate given the patient’s extensive coronary disease and the failure of percutaneous approaches [8]. CABG remains the gold standard for revascularization in patients with multivessel CAD, particularly when associated with PAD [10]. The successful outcome in this case reinforces the importance of timely surgical intervention and highlights the advancements in surgical techniques and postoperative care that contribute to improved patient outcomes.

In conclusion, this case highlights the need for a flexible and multidisciplinary approach in patients with Advanced Peripheral Artery Disease (PAD) with triple vessel CAD to ensure successful outcomes. Further studies and case reports are required to enhance the understanding and management of such complex cases.

Conflict of Interest

The authors declare no conflict of interest.

Institutional or financial support

No institutional or financial support was received.

IRB approval

The case report did not require IRB approval. 

Written consent

Written and signed consent for the publication of this case report and accompanying data has been obtained from the patient.

Ethics Statement and Author contributions

The manuscript complies with the ethical recommendations of the Declaration of Helsinki of the World Medical Association (WMA). U.A and N.D contributed to the conception and design of the manuscript. U.A and N.D supervised the project. U.A provided the materials and contributed to data collection and processing. U.A and N.D contributed to the interpretation and analysis of the project.  U.A and N.D contributed to the literature review and writing of the manuscript respectively. U.A and N.D critically revised the manuscript. 

Acknowledgements

None.