The case of the week

June, 13^rd - 2014

Double artery reconstruction for double ulcerated foot

The clinical hostory:

89 years old female

Diabetis

Hypertension

Ischemic cardiopathy

Previous endovascular intervention failed 4 months before same leg

Two ulcerated lesions: first metatarsal head and toe, and heel 

Fig. 1 - Right foot: first metatarsal head and toe ulcer

Fig. 2 - Right foot: heel ulcer

Interventional Radiologists’ strategy: perform a diagnostic angiography of right leg and foot to see which arteries are occluded and plane which arteries has to be opened in order to directly feed the two lesions.

Angiographic room: local anestesia of the right groin region. Right common femoral artery puncture and 4 french introducer sheath.

Fig. 3 - Antegrade right Common Femoral Artery approach: double critical stenosis of Superficial Femoral Artery (SFA) at the proximal tract

Fig. 4 - Superficial Femoral and Popliteal Artery (SFA) aterosclerosis with multiple mild stenosis

Fig. 5 - Complete occlusion of Below The Knee (BTK) main arteries  

Fig. 6 - Collateral vascularization above the ankle 

Fig. 7 - Very weak Dorsalis Pedis and Plantar Arteries 

Endovascular intervention starts with dilation (Percutaneous Transluminal Angioplasty) of SFA stenosis.

Fig. 8 -  Balloon inflated inside Superficial Femoral Artery (SFA) on a stenosis

Fig. 9 - No flow limiting dissections after SFA Percutaneous Transluminal Angioplasty (PTA) 

After being able to increase the flow until the origin of BTK’s vessels, we catheterize the Anterior Tibial Artery origin and we push the wire inside to re-open it. 

Fig. 10 – Recanalization technique: wire loup (just outside a balloon catheter) cuts subintimal space at proximal part of Anterior Tibial Artery

Fig. 11 - Recanalization technique: wire loup cuts subintimal space at medial part of Anterior Tibial Artery

Fig. 12 - Recanalization technique: wire loup cuts subintimal space at distal part of Anterior Tibial Artery

The wire gains the lumen of Dorsalis Pedis Artey and after we dilate the Anterior Tibial Artery just recanalized we obtain a very good flow direct to the anterior lesions of the foot. Patient feels immediate pain relief.

Fig. 13 - Contrast medium injection through balloon catheter shows the lumen of Dorsalis Pedis Artery and distal arteries inside the foot

Fig. 14 - Direct blood flow to the dorsal part and toes through Anterior Tibial Artery just recanalized and Dorsalis Pedis

And what about heel ulcer? We must open the direct artery because of a still poor vascularization of that area. Target artery is Posterior Tibial Artery and Plantar Artery

Fig. 15 – Below The Knee angiogram trying to find the origin of the total occluded Posterior Tibial Artery

In such a case we use the loup technique to find the right way, to cut the intima and create a new lumen of the diseased/occluded Posterior Tibial, at least until the region of the heel.

Fig. 16 - Recanalization technique: wire loup (just outside a balloon catheter) cuts subintimal space at middle part of Posterior Tibial Artery

Our endovascular intervention is totally successful when we obtain a direct blood flow to the foot, and even better, to the lesions

Fig. 17 – Final angiogram: Below The Knee arteries regularly patent and direct blood flow to the two ulcerations

After this endovascular intervention good result, we expect the complete heal of the ulcers in three weeks, without partial amputation, and after wound care made by a specialist of our equipe.