Below the ankle angioplasty: treatment rationale and access techniques

Abstract

Abstract A 70-year-old woman underwent an urgent endovascular below the knee therapeutic procedure in the interventional radiology department. The cause of admission was critical limb ischaemia with rest pain and extensive foot ulcer located mainly at the posterior aspect of the distal calf, the calcaneus, and the posteromedial aspect of the right foot (tissue loss, Rutherford stage 6). The patient also had a previous common femoral to popliteal artery bypass on the same leg. The ankle-brachial index was 0.6 on the right side. Following antegrade puncture, selective digital subtraction angiography showed a patent bypass graft with long total occlusions of the anterior tibial and posterior tibial arteries. The peroneal artery was the only patent tibial artery to the ankle. The area of tissue loss related to the angiosomal distribution of the posterior tibial artery, but was supplied by peroneal perforating collaterals below the ankle. The posterior tibial artery was treated with a combined antegrade and retrograde tibial approach (SAFARI technique) in order to re-establish a direct inline flow to the area of interest. An attempt to restore flow to foot via the anterior tibial artery was made, but it was unsuccessful. On the three-month surveillance follow-up with duplex ultrasound, the patient had a two-vessel run-off to the foot, the posterior tibial artery, and the peroneal artery without any significant stenosis. There was progressive healing of the tissue loss (Rutherford stage reduced from 6 to 5) and the ankle-brachial index had improved by 0.25 (from 0.6 up to 0.85).