1. Fellows Case #2: Keep Me in The Loop!
A Case Series of Critical Limb Ischemia Treated With Isolated Pedal Loop Angioplasty
Joseph DeMarco, DO
Morristown Medical Center
Morristown, New Jersey

2. Introduction
Below-the-ankle revascularization is of great importance in the contemporary treatment of critical limb ischemia (CLI) patients.
To date, studies have focused on below-the-knee revascularization.
Isolated below-the-ankle revascularization has not been independently studied.
We will present a series of 14 cases between from our institution in which below-the-ankle lesions were identified and treated using angioplasty without additional concurrent infrapopliteal or femoropopliteal intervention.

3. Case Study Demographics
A retrospective analysis of Rutherford Categories V/VI patients who underwent below-the-knee (BTK) angioplasty between 2013 and 2015 was performed.
203 total patients identified.
14 patients (7%) only required isolated below-the-ankle (BTA) intervention with percutaneous intraluminal angioplasty (PTA).
n = 14, M:F 10:4
Average age (Range) = 60.6 years (30-89)
Cardiovascular risk factors:
71% DM (n = 10)
79% HTN (n = 11)
29% CKD (n = 4)
14% Smoker (n = 2)

4. Index Case
58-y/o male with PMH of insulin-dependent DM, hyperlipidemia, and CAD s/p coronary angioplasty six years ago presents initially with a slow healing ulcer between 4th and 5th toes.
Patient denies rest pain or claudication at that time.
3 weeks later, patient returns with worsening pain, edema, and worsening ulceration.

5. Pertinent Physical Exam Findings
Femoral and popliteal pulses are palpable bilaterally.
Strongly palpable dorsalis pedis and weakly palpable posterior tibial artery pulse.
Worsening edema.
Ulcer between the left fourth and fifth digits on the left foot is enlarging, with active foul smelling exudate.
Transcutaneous Oxygen Perfusion
Marginal Dorsal foot perfusion 37mmHg at rest and 41mmHg when elevated
Adequate Plantar perfusion >100mmHg

6. Pre-Intervention Angiograms
PT, DP, and peroneal patent.
Lateral plantar artery small in caliber.
patency of the femoral popliteal segment with dominant anterior tibial artery runoff, although there is notable absence of the plantar surface of the pedal loop, including the deep plantar arteries. The posterior tibial artery is patent. Internal lateral plantar artery was very small in caliber without a complete loop. The peroneal artery was also patent. There was a moderately strong wound blush to the fourth toe on initial AP and lateral angiography.
Plantar pedal loop incomplete

7. Intervention
Posterior tibial, lateral plantar artery and plantar pedal loop cannulated with 2.6F microcatheter and 0.014” Glidewire Advantage® (Terumo, Somerset, New Jersey USA).
2.5mm angioplasty performed.
posterior tibial artery, lateral plantar artery, and plantar pedal loop were crossed with a 2.6 French microcatheter and inch Glidewire Advantage. A 2.5 mm angioplasty was performed across the plantar pedal loop and posterior tibial artery.

8. Post-Intervention Angiogram
Markedly increased lumen and flow rate in the posterior tibial artery and lateral plantar artery.
Restored patency of a complete plantar pedal loop.
Post
Pre
Enhanced wound blush to 4th/5th intertriginous region.

9. 6 Week Clinical Follow Up
Before
After
Replace slide#11

10. Dorsal Pedal Circulation Plantar Pedal Circulation
Pedal Loop Assessment
Dorsal Pedal Circulation
Plantar Pedal Circulation
Manzi M et al. Vascular Imaging of the Foot: The First Step toward Endovascular Recanalization. Radiographics 2011; 31:

11. Types of Interventions
Before
Treatment
After
Types of Interventions 1
DP / dorsal loop alone (n= 2)
PT / plantar loop alone (n= 7)
Entire plantar pedal loop (n= 3)
Other (n= 2) 2 3
Plantar circulation = medial or lat plantar
Dorsal circulation = dorsalis pedis, deep perforating
Other = MT and DP + LP (separate)

12. n
AGE S E X
Wound
Angioplasty Location
Angiographic Success
Follow Up
Clinical Healing 1 89 F
4th/5th intertriginous MP Y
No follow up. Deceased.
Unknown 2 60 M
Dorsal 1st & 3rd toes DP
Amputated hallux and 3rd toe
Pain improved
Triphasic flow into foot
Planned TMA
Healing 3 66
Plantar 1st & 2nd toe amputation site LP
No pain
GI bleed on Plavix/ASA
Healed 4 72
Calcaneal N
Triphasic flow, ABI 1.07 5 54
DP + LP
Amputated hallux
Calcaneal healed 6 51
Plantar Hallux
DP + PP
Angiogram- Pedal loop intact 7
Plantar 3rd toe
I&D 8
Dorsal Hallux
MP + DL
US Duplex Triphasic flow to foot 9 30
Lateral 3rd-5th toe amputation site MT
TcPO2 study sufficient perfusion 10 71
DP+PP+LP
New SFA stenosis
Triphasic flow to foot
TcPO2 study insufficient perfusion
Non-healing 11 58
LP+PP
Healed, LE Duplex neg, ABI nml 12 50
Plantar 2ND toe 13 56
Distal 3rd toe amputation site 14 77
Dorsal midfoot
TMA
Non-healing TMA
Replace slide #14
KEY: MP-medial plantar; LP-lateral planter; DP-dorsalis pedis/dorsal loop; PP-plantar perforator (deep plantar); DL-deep loop; MT-metatarsal

13. Results Technical Angiographic Success
Defined as <50% residual stenosis
9/14 (64%)
Clinical Follow Up (Mean days, Range days)
Complete healing: n = 5 (36%)
Partial healing: n = 5 (36%)
Non-healing: n = 2 (14%)
Amputation: n = 2 (14%), 1 planned pre-intervention
No follow up: n = 2 (14%)
Endovascular Reintervention: n = 1 (7%)
Replace slide #15

14. Discussion
Percutaneous transluminal angioplasty (PTA) has become first line management for patients with critical limb ischemia (CLI).
Below-the-ankle angioplasty has been previously described as a potential adjunct treatment to proximal angioplasty.
However, our study demonstrates that isolated below-the-ankle stenosis/occlusion can be a potential source of CLI.
Therefore, three-vessel run off cannot be used as the sole determinate of adequate perfusion for healing.
Rather, it is important to identify:
Anatomic variations in pedal arterial supply
Pedal arch integrity
Hallux and calcaneus as watershed regions
A recent study by Katsanos et al found that inframalleolar obstructive disease almost universally coexisted with more proximal femoropopliteal and/or infrapopliteal disease.
Isolated BTA lesions were identified in only 2 cases (5%).

15. Conclusions
Below-the-ankle revascularization with PTA is technically feasible and associated with clinical improvement.
Improvement in primary wound healing and post-amputation healing.
Real-time angiographic analysis rather than the angiosome model should be used to assess below-the-ankle microvasculature and determine the revascularization target.
An intact pedal arch has been associated with improved wound healing and higher patency rates.
Close clinical follow up is necessary focusing on wound healing and pain improvement instead of repeat imaging.
Follow up Doppler US is not necessary or accurate in evaluating healing caused by below-the-ankle lesions.
The use of TcPO2 measurements may be helpful in determining adequate reperfusion to promote wound healing (Redlich et al).

16. References
Abdelhamid MF, Davies RSM, Rai S, Hopkins JD et al. Below-the-ankle Angioplasty is a Feasible and Effective Intervention for Critical Leg Ischemia. Eur J Vasc Endovasc Surg 2010; 39:
Biancari F, Alback A, Ihlberg L, et al. Angiographic runoff score as a predictor of outcome following femorocrural bypass surgery. Eur J Vasc Endovasc Surg 1999;17:
Davies MG, Saad WE, Peden EK, et al. Impact of runoff on superficial femoral artery endoluminal interventions of rest pain and tissue loss. J Vasc Surg 2008;48:
Fernandez N, McEnaney R, Marone LK, Rhee RY et al. Multilevel versus Isolated Endovascular Tibial Interventions for Critical Limb Ischemia. Journal of Vascular Surgery 2011; 54 (3):
Katsanos K, Diamantopoulos A, Spiliopoulos S, Karnabatidis D and Siablis D. Below-the-ankle Angioplasty and Stenting for Limb Salvage: Anatomic Considerations and Long-term Outcomes. Cardiovasc Intervent Radiol 2013; 36:
Kawarada O, Yokoi Y, Higashimori A, Waratani N et al. Assessment of Macro- and Microcirculation in Contemporary Critical Limb Ischemia. Catheterization and Cardiovascular Interventions 2011; 78:
Lee AC and Khaddus MA. Pedal Arch Revascularization: The Rationale Behind this Procedure and Tips from Preprocedure Planning and Intervention. Endovascular Today May 2014;
Manzi M, Cester G, Palena LM, Alek J et al. Vascular Imaging of the Foot: The First Step toward Endovascular Recanalization. Radiographics 2011; 31:
Misra S, Lookstein R, Rundback J, Hirsch A et al. Proceeding from the Society of Interventional Radiology Research Consensus Panel on Critical Limb Ischemia. JVIR 2013; 24:
Rashid H, Slim H, Zayed H, Huang D et al. The Impact of Arterial Arch Quality and Angiosome Revascularization on Foot Tissue Loss Healing and Infrapopliteal Bypass Outcome. Journal of Vascular Surgery May 2013; 57 (5):
Redlich U, Xiong YY, Pech M, Tautenhahn J et al. Superiority of Transcutaneous Oxygen Tension Measurements in Predicting Limb Salvage After Below-the-Knee Angioplasty: A Prospective Trial in Diabetic Patients with Critical Limb Ischemia. Cardiovasc Intervent Radiol 2011; 34:
Zhu YQ, Zhao JG, Liu F, Wang JB, Cheng YS et al. Subintimal Angioplasty for Below-the-Ankle Arterial Occlusions in Diabetic Patients with Chronic Critical Limb Ischemia. J Endovasc Ther 2009; 16:

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