Distal Posterior Tibial Artery Research Articles

Effect of EDTA with porous balloon on calcified lesion: An atherosclerotic cadaver study.

Ethylene diamine tetra-acetic acid (EDTA) is a chelating agent used to dissolve calcium deposits but evidence in decalcifying atherosclerotic lesions is limited. We assessed the feasibility and efficacy of EDTA delivered via porous balloon to target calcified lesions in cadaveric below-the-knee (BTK) arteries. Using porcine carotid arteries, EDTA concentration was measured in the arterial wall and outside the artery at the 0-, 0.5-, 4-, and 24-h circulation after the injection through a porous balloon. In cadaver BTK samples, the proximal and distal anterior tibial artery (ATA) and distal posterior tibial artery (PTA) were studied. EDTA-2Na/H2O or EDTA-3Na/H2O were administrated using a porous balloon, then circulated for 6 h for EDTA-3Na/H2O and 24 h for EDTA-2Na/H2O and EDTA-3Na/H2O. Micro-CT imaging of the artery segments before and after the circulation and cross-sectional analyses were performed to evaluate calcium burden. In the porcine carotid study, EDTA was delivered through a porous balloon present in the arterial wall and was retained there for 24 h. In BTK arteries, cross-sectional analyses of micro-CT revealed a significant decrease in the calcium area in the distal ATA segment under 24-h circulation with EDTA-2Na/H2O and in the distal ATA segment under 24-h circulation with EDTA-3Na/H2O. The proximal ATA segment under 6-h circulation with EDTA-3Na/H2O showed no significant change in any parameters of calcium CONCLUSION: EDTA-3Na/H2O or EDTA-2Na/H2O with longer circulation times resulted in greater calcium reduction in atherosclerotic lesion. EDTA may have a potential therapeutic option for the treatment of atherosclerotic calcified lesions.

Comparative Doppler ultrasound findings of foot arteries in patients with type 2 diabetes mellitus and normoglycaemic patients

Aim of the Study:The aim of this study was to investigate lower extremity peripheral artery disease (LEPAD) in the foot arteries of patients with type 2 diabetes mellitus, with and without clinical symptoms of arterial insufficiency, using triplex Doppler ultrasound.Materials and Methods:Forty-seven consecutive adult subjects with type 2 diabetes mellitus (T2DM) and 47 age-matched and sex-matched non-diabetic controls were recruited (94 limbs each). Ankle-brachial index (ABI), fasting blood glucose assay, glycated haemoglobin assay and triplex sonography of the dorsalis pedis artery (DPA) and the distal posterior tibial artery (PTA) in both feet were performed.Results:The mean age of the subjects and controls were 60.21 ± 7.68 years and 56.81 ± 9.05 years (P > 0.05). The mean duration of diabetes mellitus was 10.4 ± 5.8 years. Crampy calf pain was the most common presenting symptom. Twenty-one (22.3%) of the 94 limbs of T2DM subjects had an abnormal ABI. Abnormal triplex Doppler waveform was seen in more than half of the PTA (57/94; 60.6%) and DPA (55/94; 58.5%). Forty-one (43.6%) of the 94 diabetic limbs had plaques in the PTA, while plaques were present in the DPA of 52 (55.3%) diabetic limbs.Conclusion:LEPAD is common in T2DM with a higher prevalence on triplex Doppler sonography compared to ABI values.

Distal arteriovenous fistula to preserve patency in COVID-19–associated acute limb ischemia

The purpose of this study was to report our institutional experience with patients with COVID-19 who developed acute limb ischemia during hospitalization and to determine the characteristics and clinical outcomes. Between March 2020 and January 2021, we treated 3 patients who were COVID-19–positive and developed acute limb ischemia after they received thromboprophylaxis. We performed an embolectomy by exposing the popliteal artery below the knee to treat an occlusion of the popliteal and tibial arteries. An infusion of unfractionated heparin was initiated immediately after surgery, maintaining a partial thromboplastin time ratio > 2.5 times the normal value and transferred the patients to the intensive care unit. However, after these patients developed recurrent acute limb ischemia in the same leg, we decided to perform an embolectomy of popliteal and tibial arteries at the ankle and created an arteriovenous fistula (AVF) with tibial veins using polypropylene 7-0. The first patient died from pneumonia after 3 weeks in the intensive care unit; at that time, the foot was viable with triphasic flow in the distal posterior tibial artery and the AVF was patent. The second and third patients are doing well, they can walk without any problems, and the tibial arteries and AFV were patent on duplex ultrasound after 6 months. The AVF allowed part of the flow of tibial arteries to divert into the small veins of the foot that have a low resistance to maintain patency of tibial vessels, despite a hypercoagulable state and extensive thrombotic microangiopathy in patients with COVID-19.

Ankle Peak Systolic Flow Velocity (PSV) with Coronary Artery Disease in Diabetes Mellitus

Introduction: Ankle peak systolic flow velocity can measure peripheral arterial blood flow which can predict extent of peripheral arterial disease. Atherosclerosis is more common in patients with diabetes mellitus and can affect simultaneously coronary circulation and peripheral circulation.
 Aims and Objectives: The primary objective of the study was to determine the occurrence of peripheral vascular disease by ankle Peak Systolic Velocity (PSV) in patients admitted for coronary artery disease with diabetes mellitus .The secondary objective was to see the association between the ankle Peak Systolic Flow Velocity (PSV) with the extent of abnormality of coronary angiogram in diabetic patients.
 Materials and Methods: All patients admitted in the hospital with coronary artery disease with diabetes mellitus in whom coronary angiogram was done were included in the study over a period of one year Presence of significant vessel disease CAD was defined as at least >70 % stenosis at one or more major coronary arteries (left anterior descending, left circumflex and right coronary artery). Ankle Peak Systolic Velocity (PSV) was measured in all patients by the Duplex method. The peak systolic velocities in the distal posterior tibial artery and the distal anterior tibial artery was measured and the average peak systolic velocities within three cardiac cycles6 was recorded by the radiologist. The ankle peak systolic flow above 40cm/s was considered as good flow in the lower limb extremity [7]. The data was analysed using SPSS version 17.0 software and mean and standard deviation was used .
 Results: Out of the cases studied 24 patients (80%) were males and 6 patients (20%) were females. All the Coronary angiograms was classified to single 13(43.3%), double 8(26.7%) and triple 9 (30%) vessel disease by the cardiologist. Out of the 13 patients with single vessel disease 3 patients had < 40 cm/s flow in the right anterior tibial artery and 10 patients had >40 cm/s flow in the right tibial artery indicating good perfusion.Out of the 8 patients with double vessel disease 4 patients had flow <40 cm/s and 4 patients had flow >40 cm/s. In triple vessel disease category 5 patients had flow <40 cm/s and 4 patients had flow>40cm/s. The p value was 0.2 was not significant and the chi square was 2.79 Similar results were obtained while compared with left ankle peak systolic flow velocity.
 Conclusion: In this study patients with single vessel disease have higher ankle peak systolic velocity though statistically not significant. Lower ankle peak systolic flow velocity corroborates with peripheral arterial disease [12] and is seen in patients with coronary artery disease [13].

THE APPLICATION OF THE DISTAL POSTERIOR TIBIAL ARTERY PERFORATOR FLAPS IN CHRONICS WOUNDS

INTRODUCTION: The reconstruction of lesions in the distal third of the leg is one of the challenges for surgeons. In this scenario, the use of posterior tibial perforator flaps is being used more and more in surgical practice due to their versatility and aesthetic results. MATERIALS AND METHODS: This research consists of an integrative review carried out from a bibliographic survey in the PUBMED and Virtual Health Library (BVS) search platforms. After reading the full 20 articles in total, an overlap of four articles present in the two searches was observed, thus resulting in a total of 16 articles included in this review. RESULTS: The treatment of chronic lower limb wounds caused by infection, diabetes mellitus and osteomyelitis has always been a formidable task. Perforator-free flaps are generally recommended as the therapy of choice in the treatment of chronic lower limb wounds. DISCUSSION: The advantages of the application of the posterior tibial artery skin flap is ideal for small leg defects to reconstruct the exposed bone and tendon. As it is local tissue, it substitutes as tissue. The distal posterior tibial artery perforator flap is a beneficial technique, in the plastic and reconstructive surgery field, especially for the treatment of chronic lower extremity wounds. Keyword : CHRONIC WOUNDS, DISTAL POSTERIAL TIBIAL ARTERY, PERFORATOR FLAP, PLASTIC SURGERY

Limb Preservation with Balloon Angioplasty in Critical Limb Threatening Ischemia: A Case Report

Introduction: Chronic limb-threatening ischemia (CLTI) is a syndrome that represents the end-stage of peripheral artery disease (PAD) that increased the risk of major amputation and cardiovascular events. The initial treatment for CLTI may significantly impact the risk of major amputation or death. Objective: This case report aims to describe limb preservation with balloon angioplasty in a Critical Limb Ischemia patient. Case Presentation: A hypertensive 72-years old female complained of left leg pain followed by a wound on her left toe four months ago. Her toe was amputated, but the wound persists. On physical examination, the pulsation was diminished in her left foot. Duplex ultrasound showed monophasic spectral doppler from left popliteal artery to distal left anterior tibial artery (ATA) and distal posterior tibial artery (PTA). CT-Angiography showed short total occlusion (2cm) at the distal left Superficial Femoral artery (SFA), multiple stenoses with maximal 90% stenosis at the left ATA, and chronic total occlusion at the proximal-mid left posterior tibial artery (PTA). She was diagnosed with CLTI left inferior extremity Fontaine IV Rutherford 5. The angiography result was similar to the CT-angiography result. The patient was successfully treated with plain balloon angioplasty from distal left SFA to distal left ATA and drug-coated balloon angioplasty from the distal left SFA to the popliteal artery. Her wound was also consulted to the surgical department. Conclusion: Appropriate revascularization is fundamental to limb preservation. We successfully perform endovas- cular strategy with TIMI flow 3 from left SFA to distal left ATA and distal PTA in our patient, but we still need further holistic CLTI management.

The Society for Vascular Surgery Population Health Task Force

The purpose of this study was to report our institutional experience with patients with COVID-19 who developed acute limb ischemia during hospitalization and to determine the characteristics and clinical outcomes. Between March 2020 and January 2021, we treated 3 patients who were COVID-19–positive and developed acute limb ischemia after they received thromboprophylaxis. We performed an embolectomy by exposing the popliteal artery below the knee to treat an occlusion of the popliteal and tibial arteries. An infusion of unfractionated heparin was initiated immediately after surgery, maintaining a partial thromboplastin time ratio > 2.5 times the normal value and transferred the patients to the intensive care unit. However, after these patients developed recurrent acute limb ischemia in the same leg, we decided to perform an embolectomy of popliteal and tibial arteries at the ankle and created an arteriovenous fistula (AVF) with tibial veins using polypropylene 7-0. The first patient died from pneumonia after 3 weeks in the intensive care unit; at that time, the foot was viable with triphasic flow in the distal posterior tibial artery and the AVF was patent. The second and third patients are doing well, they can walk without any problems, and the tibial arteries and AFV were patent on duplex ultrasound after 6 months. The AVF allowed part of the flow of tibial arteries to divert into the small veins of the foot that have a low resistance to maintain patency of tibial vessels, despite a hypercoagulable state and extensive thrombotic microangiopathy in patients with COVID-19.

Histopathological characterization of intimal lesions and arterial wall calcification in the arteries of the leg of elderly cadavers.

IntroductionAlthough arteries of the leg have been studied in extensively diseased amputation specimens, little is known about the composition of vascular lesions present in the general population. The aim of this study was to describe the natural development of adaptive intimal thickening, atherosclerotic lesion development and vascular calcification in the leg of a general elderly population.Materials and MethodsTwo hundred and seventy postmortem samples from the popliteal and posterior tibial arteries of 14 elderly cadavers were studied histologically.ResultsAtherosclerotic lesions were more frequently observed in the popliteal (60%) than in the posterior tibial artery (34%; p < .0005). These atherosclerotic plaques were most often nonatheromatous (80% and 83% for popliteal and posterior tibial plaques, respectively). The atheroma's that were present were small (most <25% of plaque area). Atherosclerotic plaque calcification was observed more often in the popliteal (39%) than in the posterior tibial samples (17%; p < .0005). Medial arterial calcification was observed more often in the posterior tibial (62%) than in the popliteal samples (46%; p = .008). Plaque calcification and medial arterial calcification were not associated with lumen stenosis.ConclusionsIn the leg of elderly cadavers, the presence of atherosclerotic plaque and intimal calcification decreases from the proximal popliteal artery to the more distal posterior tibial artery and most atherosclerotic lesions are of the fibrous nonatheromatous type. In contrast, the presence and severity of medial calcification increases from proximal to distal.

Non-contrast-enhanced MR angiography of the foot with flow spoiled-fresh blood imaging (FS-FBI): feasibility study and comparison of different scanning parameters

To evaluate the feasibility of foot arteries using flow-spoiled-fresh blood imaging (FS-FBI) and to investigate how the FS-FBI scanning parameters affect the flow sensitivity and impact the depiction of pedal arteries. The study included 46 young healthy volunteers examined by FS-FBI using 1.5T MRI scanner. Additional FS-FBI examination with different flip angles (FA) of the radiofrequency refocusing pulse and echo time (TE) was performed on 36 volunteers. Two radiologists separately analyzed and graded the venous contamination, image quality, displaying rate, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) values of foot arteries. Multi-sample Friedman test and paired two-sided Student’s t test were used for statistical analysis (P < 0.05). Average image quality and venous contamination score of all arteries was good. The demonstration rate of distal anterior and posterior tibial artery, and lateral plantar artery was 100%. Dorsalis pedis artery, first dorsal metatarsal artery, medial plantar artery, and plantar arch were demonstrated at a rate above 90%. The demonstration rate of medial tarsal artery was 73.9%, whereas arcuate artery was detected with a rate of only 5.4%. Significant differences in image quality, SNR, and CNR of distal arterial area were observed between different FA and TE. Non-contrast-enhanced MR angiography of foot using FS-FBI enables clear separation of veins from arteries, and yields reliable depiction of the foot arterial tree in healthy volunteers. Distal arterial branches of foot can be better depicted by appropriate adjustment of the flow-sensitivity parameters.

Effects of combined training with different intensities on vascular health in patients with type 2 diabetes: a 1-year randomized controlled trial

BackgroundExercise, when performed on a regular basis, is a well-accepted strategy to improve vascular function in patients with type 2 diabetes. However, the exercise intensity that yields maximal adaptations on structural and functional indices in patients with type 2 diabetes remains uncertain. Our objective was to analyze the impact of a 1-year randomized controlled trial of combined high-intensity interval training (HIIT) with resistance training (RT) vs. a combined moderate continuous training (MCT) with RT on structural and functional arterial indices in patients with type 2 diabetes.MethodsPatients with type 2 diabetes (n = 80) were randomized into an exercise intervention with three groups: control, combined HIIT with RT and combined MCT with RT. The 1-year intervention had 3 weekly exercise sessions. High-resolution ultrasonography of the common carotid artery and central and peripheral applanation tonometry were used to assess the changes in structural and functional arterial indices. Generalized estimating equations were used to model the corresponding outcomes.ResultsAfter adjusting the models for sex, baseline moderate-to-vigorous physical activity, and mean arterial pressure changes, while using the intention-to-treat analysis, a significant interaction was observed on the carotid intima-media thickness (cIMT) for both the MCT (β = − 4.25, p < 0.01) and HIIT group (β = − 3.61, p < 0.01). However, only the HIIT observed favorable changes from baseline to 1-year on peripheral arterial stiffness indices such as carotid radial arterial pulse wave velocity (β = − 0.10, p = 0.044), carotid to distal posterior tibial artery pulse wave velocity (β = − 0.14, p < 0.01), and on the distensibility coefficient (β = − 0.00, p < 0.01). No effect was found for hemodynamic variables after the intervention.ConclusionsFollowing a 1-year intervention in patients with type 2 diabetes, both the MCT and HIIT group reduced their cIMT, whereas only the HIIT group improved their peripheral arterial stiffness indices and distensibility coefficient. Taken together, HIIT may be a meaningful tool to improve long-term vascular complications in type 2 diabetes.Trial registration clinicaltrials.gov ID: NCT03144505

Reconstruction of Lower One Third Leg Defects in Single Vessel Lower Limb by Medial Hemisoleus Muscle Flap Based on Distal Posterior Tibial Artery Perforators

Background: Crushing injuries of the lower 1/3 of thelower limb always represent a challenge for reconstruction.Reconstructive options diminish with the injury of one ormore of the major vessels of the lower limb. This is a revisitof distally based medial hemi-soleus muscle flap as a valuableoption in such reconstruction.Patients and Methods: 16 patients with skin loss overlower one third of leg of various causes had pre-operativeduplex done to detect affection of anterior tibial and/or peronealvessels and confirm patency of the posterior tibial vessels.CT angiography was done for confirmation. In case of one ortwo vessels affection, sparing the posterior tibial artery, thedefects in the distal one third of the leg were reconstructedby distally based hemi-soleus muscle flap; based on the distalperforators of the medial head of the soleus muscle from theposterior tibial artery.Results: The flap survived completely in twelve caseswith total loss in one patient, partial loss in two case and localrecurrence of the excised tumour in one case.Conclusion: The distally based medial hemi-soleus muscleflap is a very good option in reconstruction of problematiclower one third skin defects especially that associated withvascular injury other than the posterior tibial vessels.

Initial Experience With the Outback Catheter for Targeted Reentry During Subintimal Angioplasty of the Infragenicular Arteries

Purpose: To report use of the Outback reentry device for targeted distal reentry during subintimal recanalization of chronic total occlusions (CTOs) in the infragenicular arteries. Methods: During an 18-month period, the Outback device was applied in 10 patients (mean age 71.8±18.8 years; 8 men) to achieve reentry at the infragenicular segment following either unsuccessful spontaneous reentry after subintimal crossing of a CTO or when a targeted reentry was desired. The mean occlusion length was 117.5±101.0 mm. Technical (device) success, overall procedure success, and reentry accuracy are reported, along with any major or minor complications. Results: The device was technically successful in achieving reentry in 9 of 10 cases; overall procedure success was achieved in 8 owing to heavy calcifications in a distal posterior tibial artery and a distal popliteal artery. The reentry accuracy was 10.8±14.6 mm. There were no major complications and only 3 minor sequelae, including 2 dissections and 1 small perforation; all were treated successfully with stenting. Conclusion: The Outback device has a high technical success rate in achieving targeted true lumen reentry in infragenicular subintimal angioplasty when spontaneous reentry is not possible or a targeted reentry is desirable.

Combined Radial-Pedal Access Strategy and Radial-Pedal Rendezvous in the Revascularization of Complex Total Occlusions of the Superficial Femoral Artery (the “No Femoral Access” Strategy)

Purpose: To describe the combined use of radial-pedal access for recanalization of complex superficial femoral artery (SFA) occlusions unsuitable for transfemoral recanalization. Technique: Patients are selected for this strategy if they have a long (≥10 cm) SFA occlusion with unfavorable aortoiliac anatomy, an absent ostial stump, or severely diseased and calcified distal reconstitution. Left radial artery and distal anterior or posterior tibial artery are accessed with 6-F and 4-F sheaths, respectively. The SFA lesion is crossed retrogradely with a 0.035-inch wire system. If retrograde crossing is not immediately successful, transradial subintimal tracking and radial-pedal subintimal rendezvous are used to allow retrograde reentry. Fifteen patients (mean age 62±5 years; 11 men) have been treated in this fashion, and frequently stented, through the tibiopedal access. Seven patients required radial-pedal rendezvous to facilitate retrograde reentry. Two patients underwent transradial iliac stenting during the same session, and 1 patient underwent transradial kissing angioplasty of the profunda. No major complication occurred in any patient. After the procedure, the pulse across the accessed tibial artery was palpable in all patients. Conclusion: In patients with long and complex SFA occlusion unsuitable for transfemoral recanalization, a radial-pedal strategy can overcome revascularization obstacles.

Characterization of tibial velocities by duplex ultrasound in severe peripheral arterial disease and controls

The relationship between tibiopopliteal velocities and peripheral arterial disease (PAD) severity is not well understood. We sought to characterize tibiopopliteal velocities in severe PAD and non-PAD control patients. Patients with an arterial duplex ultrasound (DUS) examination with PAD evaluated during a 5-year period were retrospectively compared with non-PAD controls. Control DUS examinations were collected sequentially during a 6-month period, retrospectively. PAD patients included those with lifestyle-limiting intermittent claudication warranting revascularization and patients with critical limb ischemia, defined as ischemic rest pain, gangrene, or a nonhealing ischemic ulcer. For each, tibial and popliteal artery peak systolic velocity (PSV) was measured at the proximal, mid, and distal segment of each artery, and a mean PSV for each artery was calculated. Mean PSV, ankle-brachial indices, peak ankle velocity (PAV), average ankle velocity (AAV), mean tibial velocity (MTV), and ankle-profunda index (API) were compared between the two groups using independent t-tests. PAV is the maximum PSV of the distal peroneal, posterior tibial (PT), or anterior tibial (AT) artery; AAV is the average PSV of the distal peroneal, PT, and AT arteries; MTV is calculated by first averaging the proximal, mid, and distal PSV for each tibial artery and then averaging the three means together; API is the AAV divided by proximal PSV of the profunda. DUS was available in 103 patients with PAD (68 patients with critical limb ischemia and 35 patients with intermittent claudication) and 68 controls. Mean ankle-brachial index in the PAD group was 0.64 ± 0.25 compared with 1.08 ± 0.09 in controls (P = .006). Mean PSVs were significantly lower in PAD patients than in controls at the popliteal (64.6 ± 42.2 vs 76.2 ± 29.6; P = .037), peroneal (34.3 ± 26.4 vs 53.8 ± 23.3; P < .001), AT (43.7 ± 31.4 vs 65.4 ± 25.0; P < .001), and PT (43.4 ± 42.3 vs 74.1 ± 30.6; P < .001) and higher at the profunda (131.5 ± 88.0 vs 96.2 ± 44.8; P = .001). Tibial parameters including PAV (52.6 ± 45.0 vs 86.9 ± 35.7; P < .001), AAV (37.4 ± 26.4 vs 64.5 ± 21.7; P < .001), MTV (41.7 ± 30.4 vs 65.4 ± 21.7; P < .001), and API (0.43 ± 0.45 vs 0.75 ± 0.30; P < .001) were significantly lower in the PAD group than in controls. Nonoverlapping 95% confidence interval reference ranges were established for severe PAD and non-PAD controls. This study aims to characterize lower extremity arterial PSVs and ankle parameters in severe PAD and non-PAD controls. These early criteria establish reference ranges to guide vascular laboratory interpretation and clinical decision-making.

Salvage of a free flap using postoperative percutaneous angioplasty in patients with diabetic foot ulcers.

Salvage of a free flap using postoperative percutaneous angioplasty in patients with diabetic foot ulcers.

Posttraumatic arteriovenous fistula of the distal posterior tibial artery as cause of delayed wound healing in an unrecognized arterial injury.

Background Cases of posttraumatic arteriovenous (AV) fistula of the distal lower limb are rarely reported. Time from trauma to diagnosis varies from hours to years. Case Description This case report of a 51-year-old male patient shows very impressively the extensive consequences of an unrecognized traumatic AV fistula. The fistula developed here after a car accident led to a massive healing delay in a pilon fracture of the tibia and a wound, resulting in almost 1 year immobilization, 20 operations, and extensive pain drug therapy. After surgical revision of the fistula, bone and wound healing improved quickly. Conclusions The possibility of an AV fistula should be considered in case of persistent swelling after high-energy trauma of an extremity. The therapy of choice is surgery and the long-term result of successful fistula ligature is excellent.

Popliteal Versus Tibial Retrograde Access for Subintimal Arterial Flossing with Antegrade–Retrograde Intervention (SAFARI) Technique

This study aimed to ascertain differences in benefit and effectiveness of popliteal versus tibial retrograde access in subintimal arterial flossing with the antegrade-retrograde intervention (SAFARI) technique. This was a retrospective study of SAFARI-assisted stenting for long chronic total occlusion (CTO) of TASC C and D superficial femoral lesions. 38 cases had superficial femoral artery lesions (23 TASC C and 15 TASC D). All 38 cases underwent SAFARI-assisted stenting. The ipsilateral popliteal artery was retrogradely punctured in 17 patients. A distal posterior tibial (PT) or dorsalis pedis (DP) artery was retrogradely punctured in 21 patients, and 16 of them were punctured after open surgical exposure. SAFARI technical success was achieved in all cases. There was no significant difference in 1-year primary patency (75% vs. 78.9%, p = .86), secondary patency (81.2% vs. 84.2%, p = .91) and access complications (p = 1.00) between popliteal and tibial retrograde access. There was statistical difference in operation time between popliteal (140.1 ± 28.4 min) and tibial retrograde access with PT/DP punctures after surgical vessel exposure (120.4 ± 23.0 min, p = .04). The SAFARI technique is a safe and feasible option for patients with infrainguinal CTO (TASC II C and D). The PT or DP as the retrograde access after surgical vessel exposure is a good choice when using the SAFARI technique.

Below-the-ankle Angioplasty and Stenting for Limb Salvage: Anatomical Considerations and Long-term Outcomes

To report the long-term angiographic and clinical results in a series of below-the-ankle (BTA) angioplasty procedures and to present some biomechanical issues related to the unique anatomical geometry of the ankle. We performed a retrospective analysis of BTA angioplasty procedures. Clinical end points included technical success, patient mortality, salvage of the treated foot, and repeat target lesion revascularization. Imaging end points included primary patency, binary restenosis of the target lesion at the 50% threshold, and stent integrity (stent fracture, deformation, or collapse). Univariate subgroup analysis was performed. In total, 40 limbs in 37 patients (age 73.5 ± 8.2 years) with critical limb ischemia were included and 42 inframalleolar lesions (4.2 ± 1.4 cm) were analyzed. Technical success was achieved in 95.2% (40 of 42). Provisional stent placement was performed in 45.2% (19 of 42). Two patients died, and two major amputations occurred up to 3 years. At 1 year, overall primary vessel patency was 50.4 ± 9.1%, lesion binary restenosis rate was 64.1 ± 8.3%, and repeat intervention-free survival was 93.6 ± 4.3% according to life table analysis of all treated lesions. Pairwise subgroup analysis showed that BTA self-expanding stents were associated with significantly higher restenosis and poorer primary patency compared to plain balloon angioplasty or sirolimus-eluting balloon-expandable stents. Significant deformation and/or fracture of balloon-expandable stents placed BTA were identified in five of 11. Dynamic imaging showed that the dorsalis pedis artery is kinked during foot dorsiflexion, whereas the distal posterior tibial artery is kinked during plantar flexion of the foot. BTA angioplasty for critical limb ischemia treatment is safe and feasible with satisfactory long-term results. BTA stent placement must be reserved for bailout indications.

Ruptured Mycotic Infrapopliteal Aneurysm

Aneurysms involving infrapopliteal arteries are rare. Ruptured infrapopliteal aneurysms are particularly uncommon and represent a surgical or endovascular emergency. A 57-year-old man presented with a 12-cm ruptured aneurysm of the tibioperoneal trunk 5 years after an episode of bacterial endocarditis. The patient was asymptomatic until he presented acutely with a rapid expansion in the size of the left leg. Computed tomography angiography confirmed presence of a large ruptured aneurysm with chronic destruction of the adjacent tibia. The surgical approach included operative exclusion of the aneurysm via medial leg incision. Proximal control was obtained of the superficial femoral artery, and once the aneurysm was opened and decompressed, the leg was exsanguinated with an elastic bandage and hemostasis was obtained with a tourniquet. The aneurysm was ligated from within the sac, and vascular continuity was restored with a reversed contralateral saphenous vein graft from the superficial femoral artery to the distal posterior tibial artery. This aneurysm was suspected to be mycotic, although no microorganisms were recovered. Review of English literature suggests this is the largest infrapopliteal aneurysm reported. We describe a unique surgical approach using extremity exsanguination and tourniquet for vascular control after aneurysm decompression to control hemorrhage, followed by successful restoration of arterial circulation.

The “SAFARI” Technique Using Retrograde Access Via Peroneal Artery Access

The "SAFARI" technique or subintimal arterial flossing with antegrade-retrograde intervention is a method for recanalisation of chronic total occlusions (CTOs) when subintimal angioplasty fails. Retrograde access is usually obtained via the popliteal, distal anterior tibial artery (ATA)/dorsalis pedis (DP), or distal posterior tibial artery (PTA). Distal access via the peroneal artery has not been described and has a risk of continued bleeding, leading to compartment syndrome due to its deep location. We describe our experience in two patients with retrograde access via the peroneal artery and the use of balloon-assisted hemostasis for these retrograde punctures. This approach may potentially give more options for endovascular interventions in lower limb CTOs.