Plantar Artery Research Articles

Blunt traumatic true aneurysm of lateral plantar artery: A rare entity

Traumatic lateral plantar artery aneurysms to the foot is a rare entity, for the amount of trauma the foot is subjected. In the literature, till now, cases reported were after penetrating injury to the sole or associated with bony injuries. No cases of blunt trauma incidence have been reported till now. Management is by open surgical repair or endovascular repair. Pain on walking was the reason the patient attended us. In this study, we discuss a case of blunt traumatic lateral plantar artery aneurysm with its presentation and management.

Rare variation of third dorsal metatarsal artery of the horse

The purpose of this case report is to describe and document a rare anatomical variation of the cranial and caudal tibial arteries seen in a mare. During routine dissection, a deviation of the great metatarsal artery (third dorsal metatarsal artery) of the right limb of a horse was detected. The artery was smaller than usual and localised between the third and the fourth metatarsal bone, while the main blood supply of the digit wаs recеived by the medial plantar artery. Deviation of the artery of the left limb and of the veins of both limbs was not detected. This variation of the main arterial vessel topography is important not only for anatomy but also for the evaluation of the normal pulse, inflammatory processes of the digit and the hoof, occlusion of the artery itself, as well as in performing conduction ana­esthesia and surgery in the metatarsal area of the horse.

Surgical revascularization and reconstruction procedures in diabetic foot ulceration.

This article summarizes surgical procedures for preservation of the foot in diabetic patients with peripheral artery disease. Distal bypass surgery performed to perigeniculate arteries and to an isolated 'blind' popliteal segment with visible collaterals can be performed with limb salvage rates close to what can be achieved with standard bypass to crural arteries. This is also the case when performing bypass to the dorsalis pedis artery. Bypass to the medial or lateral plantar artery or to the lateral tarsal artery is associated with a relatively high rate of early occlusion, but in the patients who have persistently open grafts, limb salvage is common. The use of an arteriovenous fistula as an adjunct to distal bypass surgery does not improve prognosis. Venous arterialization, either creating retrograde perfusion of the superficial or of the deep veins of the foot has been successful in several cases although it is difficult to predict which patients will benefit. Reconstructive surgery is often performed in a multidisciplinary team including plastic surgeons. In patients with need of more extensive cover of defects, the transplant of muscular or fasciocutaneous free flaps has provided good results in the few centres that have applied this technique. This procedure can be combined with a revascularization in the same session or at a later stage. A majority of the described techniques can be implemented in most vascular centres and they should be considered in complicated cases when standard methods of revascularization and reconstruction do not suffice.

Pedal Arch Patency Guarantees Wound Healing and Limb Salvage of Transmetatarsal Amputation Following Limb Revascularization

Introduction - Transmetatarsal amputation(TMA) is necessary whenever several toes or the forefoot are affected by gangrene due to peripheral arterial disease (PAD). Revascularization before TMA is mandatory to guarantee wound healing. Currently, factors that may affect TMA healing are not well investigated. The study's aim was to evaluate the role of foot arteries in TMA healing and limb salvage after revascularization. Methods - All patients treated for PAD with chronic limb threatening ischemia(CLTI) between April-2012 and November-2017 were collected in a prospective database. Retrospective analysis was performed including only patients who underwent TMA after any type of revascularization (surgical, endovascular). Patient's demographics and clinical characteristics were assessed. Pre-operative digital subtraction angiography(DSA) were reviewed together with interventional data to determine the patency of foot arteries and the presence of in-line flow to the foot. The pedal arch patency was classified1 as: no pedal arch(NPA), incomplete pedal arch(IPA) and complete pedal arch(CPA). Clinical and Duplex follow-up was performed at 3,6 and every 6 month thereafter. The study's primary endpoints were: wound healing (WH), Limb Salvage(LS) and impact of foot arteries and pedal arch patency on LS and WH on the basis of Chi square test and Log-Rank test in the Kaplan-Meier analysis. Secondary endpoints were: primary(PP), assisted(AP) and secondary patency(SP) and patient survival(S). Results - A total of 112 limbs in 105 patients (median age 72 ±10 years, male 76.2%, 7 patients treated bilaterally) satisfying the inclusion criteria were treated in the study period. Complete data on the foot arteries were available in 104(93%) limbs. Coronary artery disease, diabetes mellitus, kidney disease and chronic obstructive pulmonary disease(COPD) were present in 39.6%, 67.6%, 52%(dialysis 28.1%) and 38.4%, respectively. Clinical presentation was Rutherford stages 5 and 6 in 10.7% and 89.3%, with 69.7% of wounds presenting infection. Surgical and endovascular revascularization were performed in 37.5% and 62.5% of cases with a technical success of 87.5%. Dorsalis pedis and common plantar arteries patency, NPA, IPA and CPA were found in 55.8%, 54.8%, 21.2%, 60.6% and 18.3%, respectively. Direct in-line flow to the foot arteries was achieved in 72.1% of cases. The mean follow-up was 17.7 months. WH was 57.1%, 89.3% and 98.2% at 6,12 and 24-month, respectively. LS was 81.1%, 79.5% and 77.5% at 6,12 and 24-month, respectively. The study's secondary endpoints are reported in table 1. TMA healing and limb salvage were not affected by patency of either dorsalis pedis artery or plantar artery (P=0.26 and P=0.33, respectively). Similarly, direct in-line flow was not associated with better wound healing and limb salvage rates (P=0.12 and P=0.35, respectively). In contrast, the presence of CPA compared to IPA or NPA was associated with higher wound healing (at 12-month: 93.3% vs 83.3%. P=0.01) and limb salvage rates (at 12-month: 100% vs 75%. P=0.019).Table 1secondary endpoints at 6,12 and 24-monthPP (%)AP (%)SP (%)S (%)6-month68.471.177.869.112-month57.362.571.86424-month50.855.668.452.1 Open table in a new tab Conclusion - The study results suggest that the pedal arch patency has a principal role in wound healing and limb salvage after transmetatarsal amputation in patients with CLTI undergoing limb revascularization.

Evaluation of peripheral artery disease with the TIVITA® Tissue hyperspectral imaging camera system.

Objective, reliable and easy screening for peripheral artery disease (PAD) is essential to confirm the diagnosis and initiate the respective treatment. Therefore, a new non-invasive hyperspectral camera (TIVITA® Tissue) was tested in patients with and without PAD. It was hypothesized that the oxygenation parameters of the TIVITA® Tissue correlate to established modalities for detection of PAD and allow differentiation between individuals with and without PAD. Evaluation of tissue oxygenation was performed in the angiosome of the medial plantar artery in 25 healthy young people and in 24 patients with and 25 patients without PAD in comparable age. Thereby, superficial oxygenation (StO2) and near-infrared (NIR) perfusion index were measured with the TIVITA® Tissue. Additionally, the ankle-brachial-index (ABI), the complaint free walking distance and the vascular quality of life were assessed and demographic data were obtained from all participants. TIVITA® Tissue analysis revealed significantly reduced StO2 and NIR perfusion index in PAD compared to healthy young participants and patients without PAD. StO2 and NIR perfusion index positively correlated with ABI, the complaint free walking distance and the vascular quality of life score. In summary, this new hyperspectral imaging camera bears great potential for PAD screening as well as for follow up.

Doppler Flow Measurement of Lower Extremity Arteries Adjusted by Pulsatility Index.

OBJECTIVE. The purposes of this study were to estimate the blood volume flow of the lower extremities by means of Doppler technique; to establish a quantitative relationship between volume flow and pulsatility index (PI) in both healthy subjects and patients with peripheral artery disease (PAD); and to derive arterial blood flow equations in the lower extremities for more accurate volume flow estimations. SUBJECTS AND METHODS. Sixty healthy subjects were recruited. Arterial diameter, peak systolic velocity, PI, time-averaged mean velocity, and volume flow of right lower extremity arteries were measured with duplex Doppler ultrasound. Linear regression analysis was used to evaluate the relationship between volume flow and the reciprocal of PI. This quantitative relationship was also used to assess flow changes in 10 patients with PAD before, after, or both before and after percutaneous angioplasty. RESULTS. Volume flow in the common femoral artery was 434.4 mL/min; superficial femoral artery, 172.5 mL/min; popliteal artery, 92.1 mL/min; dorsalis pedis artery, 11.8 mL/min; and common plantar artery, 12.0 mL/min. Linear relationships between the reciprocal of PI and volume flow were found and expressed as linear blood flow equations. For the patients with PAD, no statistical increase in measured flow in the downstream artery after percutaneous angioplasty was found (p = 0.1), although four arteries had decreased flow. After normalization of flow measurements with PI values, however, statistical increases were observed between percentage increment (p < 0.001) calculations. CONCLUSION. When real-time PI values are factored into blood volume flow calculations in the evaluation of lower extremity arteries, discrepancies in flow measurements can be resolved, resulting in more accurate and stable measurements of clinical and diagnostic significance.

Minimally Invasive Retrograde Method of Harvesting the Flexor Hallucis Longus Tendon: A Cadaveric Study

Category:AnkleIntroduction/Purpose:Utilization of the flexor hallucis longus (FHL) tendon is well described for several tendon augmentation procedures. Recently, several authors have described a minimally invasive (MI) technique to harvest the tendon utilizing a hamstring tendon stripper. The purpose of this study was to evaluate the safety and effectiveness of harvesting the FHL tendon utilizing this novel technique.Methods:The FHL tendon was harvested through a transverse plantar incision over the interphalangeal joint of the great toe in 10 fresh-frozen cadaver lower extremities. Complications, tendon length and interconnections between the FHL and flexor digitorum longus (FDL) were recorded. The specimens were then dissected by a single surgeon in a standardized fashion and damage to any surrounding structures was recorded.Results:The average length of the FHL tendon from the distal stump to the 1st inter-tendinous connection was 13.33 cm (range 8.8-16 cm, SD: 2.28 cm). Eight cadavers demonstrated Plaass Type 1 interconnections while 2 were Type 3. There was no injury to the medial and lateral plantar arteries or nerves, plantar plate or FDL tendons. One FHL tendon was amputated during graft harvesting.Conclusion:Care must be taken when approaching the sustentaculum with the tendon harvester in order to avoid amputation of the graft against a hard bony endpoint. Additionally, flexion and extension of the lateral toes can aid in successful tendon harvest when tendon interconnections are encountered. Utilizing this MI technique appears to be a safe and effective way to obtain a long FHL tendon graft tissue augmentation.

Location of the Deep Plantar Artery: A Cadaveric Study.

The deep plantar (D-PL) artery originates from the dorsalis pedis artery in the proximal first intermetatarsal space, an area where many procedures are performed to address deformity, traumatic injury, and infection. The potential risk of injury to the D-PL artery is concerning. The D-PL artery provides vascular contribution to the base of the first metatarsal and forms the D-PL arterial arch with the lateral plantar artery. In an effort to improve our understanding of the positional relationship of the D-PL artery to the first metatarsal, dissections were performed on 43 embalmed cadaver feet to measure the location of the D-PL artery with respect to the base of the first metatarsal. Digital images of the dissected specimens were acquired and saved for measurement using in-house software. Means, standard deviations, and 95% confidence intervals (CIs) were calculated for all of the measurement parameters. We found that the origin of the D-PL artery was located at a mean ± SD of 11.5 ± 3.9 mm (95% CI, 4.5-24.7 mm) distal to the first metatarsal base and 18.6% ± 6.5% (95% CI, 8.1%-43.4%) of length in reference to the proximal base. The average interrater reliability across all of the measurements was 0.945. This study helps clarify the anatomical location of the D-PL artery by providing parameters to aid the surgeon when performing procedures in the proximal first intermetatarsal space. Care must be taken when performing procedures in the region to avoid unintended vascular injury to the D-PL artery.

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.

"The Renal Foot" - Angiographic Pattern of Patients with Chronic Limb Threatening Ischemia and End-Stage Renal Disease.

Patients with chronic limb threatening ischemia (CLTI) and end-stage renal disease (ESRD) have greater risk of limb loss compared to those with CLTI alone. We investigated angiographic patterns in patients with CLTI and evaluated for differences based on ESRD status. We reviewed lower extremity angiograms of 152 CLTI patients at a single academic medical center from 2011 to 2017 and analyzed them based on the Graziani and Bollinger classification systems. We used these classification systems to evaluate for angiographic patterns and arterial disease severity categorized by the presence or absence of ESRD. The analysis included 152 CLTI patients (161 angiograms). Patients' mean age was 63.4 ± 11.3 years and 20 (12.4%) patients had ESRD. In our study population, infrapopliteal arterial disease was more severe than femoropopliteal disease. Disease of the arteries providing direct flow to the plantar arch was more severe in ESRD patients compared to non-ESRD patients, evident by higher Graziani Class VII disease (20% vs. 4.9%, p = .03). ESRD patients also had higher rates of concurrent significant stenosis of the posterior tibial and lateral plantar arteries (70% vs. 23%, p < .0001). In people with CLTI, infrapopliteal arteries are more severely affected than proximal femoropopliteal arteries. ESRD patients exhibit a pattern of arterial disease, we termed the "renal foot," that frequently involves arteries providing direct flow to the plantar arch.

Neurotized Free Tissue Transfer for Foot Reconstruction: A Systematic Review.

Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.

Minimally Invasive Retrograde Method of Harvesting the Flexor Hallucis Longus Tendon: A Cadaveric Study.

Use of the flexor hallucis longus (FHL) tendon is well described for several tendon augmentation procedures. Harvesting the FHL through an open medial approach is commonly done, but is associated with anatomic risks. Recently, several authors have described a minimally invasive (MI) technique to harvest the FHL tendon utilizing a hamstring tendon stripper commonly used in ACL reconstruction. The purpose of this study was to evaluate the safety and effectiveness of harvesting the FHL tendon using this novel minimally invasive retrograde approach. The FHL tendon was harvested through a transverse plantar incision over the interphalangeal joint of the great toe in 10 fresh-frozen cadaver lower extremities. A lateral-based incision for peroneal tendon repair was made and the FHL was retrieved. Tendon length, complications, and interconnections between the FHL and flexor digitorum longus (FDL) were recorded and classified. The specimens were then dissected by a single surgeon in a standardized fashion, and damage to any surrounding structures was recorded. The average length of the FHL tendon from the distal stump to the first intertendinous connection was 13.3 cm (range 8.8-16 cm, SD 2.3 cm). Eight cadavers demonstrated Plaass type 1 interconnections whereas 2 demonstrated type 3. There was no injury to the medial and lateral plantar arteries and nerves, plantar plate, or FDL tendons. One FHL tendon was amputated at the level of the sustentaculum during graft harvest. No injury of the medial neurovascular structures occurred with retrieval of the FHL tendon through the lateral incision. We found that care must be taken when approaching the sustentaculum with the tendon harvester in order to avoid amputation of the graft against a hard bony endpoint. Additionally, flexion and extension of the lesser toes could aid in successful tendon harvest when tendon interconnections were encountered. Using this MI technique appears to be a safe and effective way to obtain a long FHL tendon graft for tissue augmentation.

Novel Technique for Toe-to-Hand Transplantation: The Fourth-toe as an Alternative Option for Toe-to-Hand Transplantation for Pediatric Patients

The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons' skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique's development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.

642-P: Diagnosing Peripheral Neuropathy with a Remote Temperature Monitoring Mat

The aim of this study was to derive and validate a model to identify peripheral sensory neuropathy using remote temperature monitoring (RTM). We used data from a recent longitudinal study of a once-daily in-home RTM mat. Neurological status was assessed via 10g monofilament. We trained and cross-validated (repeated k-fold sampler) machine learning classifiers (support vector machine with radial basis function kernels). Accuracy was defined as the area under the receiver operator curve (AUC). We report on three final models that assess neuropathic status: (1) foot temperatures at the six plantar locations commonly used for RTM; (2) high-resolution foot temperature maps (thermograms); (3) high-resolution foot shape without associated temperatures. A total of 154 feet were included, of which 30 were insensate (19.5%). The AUCs of these three models were 0.78±0.13 (good), 0.92±0.07 (excellent), and 0.54±0.16 (poor), respectively. The results suggest the diagnostic usefulness of thermograms, which is supported by the fact that analysis feature importance of model 2 shows high diagnostic value for temperatures in the medial midfoot and distal toes. The latter is possibly due to vasodilation of the medial plantar artery, while the former can be explained by the progressive nature of neuropathy from distal to proximal. That model 3 had nearly no predictive value suggests that foot deformity secondary to motor neuropathy is not contributing diagnostic value. Interestingly, 22 feet showed neuropathic progression over the 34-week study. Results from model 1 reflected these changes when assessed at enrollment and at study completion for these feet. These results suggest the RTM mat may be useful for assessing peripheral neurological function and progression in patients with diabetes. These diagnostic models may also inform improved RTM standard and machine learning algorithms for predicting diabetic foot complications secondary to neuropathy. Disclosure B.J. Petersen: Employee; Self; Podimetrics. Stock/Shareholder; Self; Podimetrics. M. Zhou: None. J.D. Bloom: Employee; Self; Podimetrics. Stock/Shareholder; Self; Podimetrics. G.M. Rothenberg: Consultant; Self; Podimetrics. D. Armstrong: None.

Passive Hallux Adduction Decreases Lateral Plantar Artery Blood Flow in Low Arch Feet

Passive Hallux Adduction Decreases Lateral Plantar Artery Blood Flow in Low Arch Feet

Computed tomography perfusion study evaluating the curative effect of tibial transverse transport in patients with severe diabetic foot

BackgroundThe clinical treatment of patients with severe diabetic foot (DF) is difficult. Recently, the First Affiliated Hospital of Guangxi Medical University began to apply tibial transverse transport (TTT) in patients with DF. This treatment has achieved significant effects, but its mechanism of action is unclear. Recently, microcirculation and the pathogenesis of diabetes have become the foci of research in this field. The evaluation of the possible mechanism of microcirculation reconstruction requires relevant indicators. The aim of this study was to investigate the value of computed tomography perfusion in evaluations of the curative effects of TTT and establish corresponding quantitative evaluation indicators. MethodsTwelve patients with DF treated with TTT were recruited as the research participants. All diabetic feet were divided into the transport foot (TF) group and nontransport foot (NTF) group according to whether the patients underwent TTT. All patients underwent CT shuttle scanning preoperatively and 8 weeks after surgery. The shuttle scan data were transferred to Siemens VPCT body software and postprocessed with Customized Tumor2. We chose the TF posterior tibial artery from a distance of approximately 15 cm to the bifurcation of the plantar medial artery and the lateral plantar artery as the input artery. We selected the centre of the bilateral medial plantar muscle group on the coronal and axial regions of interest. We applied a deconvolution approach to obtain data from both sides of the plantar tissue perfusion. Skin temperature (ST) detection was performed with an ST gun to measure the average ST values in the dorsal and plantar areas, the first and fifth heads of the phalanges, and the medial and lateral malleolus points of both feet of patients with DF preoperatively and 8 weeks after surgery. ResultsThe preoperative and postoperative ST values of the patients in the TF group were 30.73 ± 1.86 °C and 32.22 ± 1.51 °C, respectively. The preoperative and postoperative ST values for the patients in the NTF group were 30.93 ± 2.65 °C and 32.07 ± 2.09 °C, respectively. There were significant differences in the preoperative and postoperative data between the TF (P = 0.001) and NTF (P = 0.013) groups. In the patients with DF who underwent TTT, there were both preoperative and postoperative differences inside the medial plantar muscle group in the relative blood volume (rBV) value and relative mean transit time (rMTT) (P = 0.027, P = 0.026, respectively). The postoperative BV in the NTF group was increased compared with the preoperative BV (P = 0.006). ConclusionThere were significant differences in relative BV, relative mean transit time, and ST between the two groups before and after surgery, and the postoperative BV in the NTF group and ST values in the two groups were increased compared with the preoperative values. The BV in the NTF group and the ST values in the two groups were effective indicators in evaluating the changes between preoperative and postoperative perfusion. These results indicate that TTT could increase plantar tissue perfusion as assessed by BV and ST; this increase was among the reasons for the surface healing of severe DF ulcers. Translational potential of this articlePreoperative CT perfusion evaluation can provide relevant information of blood vessels and microcirculation for clinical operation, and postoperative CT perfusion evaluation can provide postoperative efficacy evaluation for clinical operation. All patients received information about the study and signed a specific informed consent. Approval for this study was granted by the regional ethics committee [Regional Ethics Committee of the First Affiliated Hospital of Guangxi Medical University, China [(2018-(KY-E-069].

Plantar Acceleration Time: A Novel Technique to Evaluate Arterial Flow to the Foot

Arterial duplex ultrasound (DUS) and ankle-brachial indices (ABIs) are accepted methods for assessing lower limb arterial perfusion. However, in a significant number of diabetic patients, medial wall calcification often precludes an ABI measurement. Direct, noninvasive duplex imaging of the pedal arch in the setting of peripheral arterial disease (PAD) has not been well evaluated. Although plantar arch interrogation is new to vascular ultrasound, imaging the plantar arteries appears to be a reliable angiographic technique for critical limb ischemia. We sought to define the utility of Plantar Acceleration Time as a surrogate for ABIs. Patients undergoing DUS including Plantar Acceleration Time for suspicion of PAD were retrospectively reviewed in a prospective database over a 1-year period. Two hundred fifty nondiabetic patients (499 limbs) with documented ABI were studied. Plantar Acceleration Time was calculated (milliseconds [msec]) in each limb in the lateral plantar artery. Statistical analyses were performed using linear regression and analysis of variance testing using Microsoft Excel database (version 2016; Microsoft Corp, Redmond, WA). Patients were then grouped into 4 classes based on their clinical symptoms and ABI. Plantar Acceleration Time was similarly grouped into 4 distinct classes and correlated with the clinical and ABI classes. Plantar Acceleration Time correlated significantly with ABI (P<0.001). There were significant differences in Plantar Acceleration Times between each class based on ABI and clinical presentation (P<0.001 for each): Class 1 Plantar Acceleration Times 89.9±15.5msec; Class 2, 152.3±28.4msec; Class 3, 209.8±25.5msec, and Class 4, 270.2±35.3msec. Plantar Acceleration Time demonstrates a high correlation with ABI in patients with compressible arteries. Based on our results we propose the following categories of Plantar Acceleration Time, which appear to correlate with both clinical and ABI findings. ABI of 0.90-1.3 correlates with a Plantar Acceleration Time of 0-120msec, ABI of 0.69-0.89 correlates with a Plantar Acceleration Time of 121-180msec, ABI of 0.40-0.68 correlates with a Plantar Acceleration Time of 181-224msec, and an ABI of 0.00-0.39 correlates with a Plantar Acceleration Time of greater than 225msec. Further studies are ongoing to confirm whether Plantar Acceleration Time may be a suitable substitute to ABIs in patients with noncompressible arteries that preclude meaningful ABIs and gives more information regarding targeted angiosome perfusion to the foot.

Alleviation of mechanical stress-induced allodynia by improving blood flow in chronic constriction injury mice

Reduced blood flow in the skin is observed in patients with neuropathic pain and in animal models. The aim of the present study was to elucidate the relationship between reduced skin blood flow and neuropathic pain in mice with a chronic constriction injury (CCI). Noradrenaline-induced contraction was enhanced in isolated plantar arteries ipsilateral to the CCI surgery compared to the contralateral arteries. Ten μM hydralazine, a peripheral vasodilator, at improved the enhanced contractile response in the ipsilateral arteries. The plantar blood flow in vivo was lower on the ipsilateral side of the CCI mice than on the contralateral side, and a 50% paw withdrawal threshold, as measured using the von Frey filament test, was lower on the former than on the latter side. An intraperitoneal injection (i.p.) of hydralazine (1 mg/kg) or phentolamine (5 mg/kg) improved blood flow in the skin and hyperalgesia in the ipsilateral plantar. In adrenalectomized CCI mice, plantar blood flow in the skin on the ipsilateral side was increased compared to in sham-operated mice, which was accompanied by alleviation of hyperalgesia. Moreover, the enhanced contractile response to noradrenaline was also observed in the ipsilateral plantar arteries isolated from the adrenalectomized CCI mice. Either hydralazine (1 mg/kg, i.p.) or an adrenalectomy barely affected mean arterial pressure in the CCI mice, whereas phentolamine (5 mg/kg, i.p.) lowered it. These results suggest that reduced blood flow in the skin contributes to neuropathic pain and that improving that blood flow with peripheral vasodilators, such as hydralazine, can alleviate it.

Passive hallux adduction decreases lateral plantar artery blood flow: a preliminary study of the potential influence of narrow toe box shoes

BackgroundBlood flow is essential in maintaining tissue health. Thus, compromised blood flow can prevent tissue healing. An adducted hallux, as seen inside a narrow shoe, may put passive tension on the abductor hallucis, compressing the lateral plantar artery into the calcaneus and restricting blood flow. The purposes of this study were to compare lateral plantar artery blood flow before and after passive hallux adduction and to compare blood flow with arch height.MethodsForty-five healthy volunteers (20 female, 25 male; age = 24.8 ± 6.8 yr; height = 1.7 ± 0.1 m; weight = 73.4 ± 13.5 kg) participated in this cross-over design study. Arch height index (AHI) was calculated, and blood flow measurements were obtained using ultrasound (L8-18i transducer, GE Logiq S8). The lateral plantar artery was imaged deep to abductor hallucis for 120 s: 60 s at rest, then 60 s of passive hallux adduction. Maximal passive hallux adduction was performed by applying pressure to the medial side of the hallux. Blood flow was calculated in mL/min, and pre-passive hallux adduction was compared to blood flow during passive hallux adduction.ResultsLog transformed data was used to run a paired t-test between the preadduction and postadduction blood flow. The volume of blood flow was 22.2% lower after passive hallux adduction compared to before (− 0.250 ± 0.063, p < 0.001). As AHI decreased, there was a greater negative change in blood flow. As baseline blood flow increased, there was also a greater negative change in blood flow.ConclusionsOur preliminary findings of decreased blood flow through passive hallux adduction indicate conditions that elicit passive hallux adduction (e.g. wearing narrow-toed shoes) may have important effects on foot blood flow. Individuals with lower AHI appear to have a greater risk of decreased blood flow with passive hallux adduction.

Medial Plantar Artery Perforator Flap: Experience with Soft-tissue Coverage of Heel.

Background:Soft-tissue coverage is a challenge to the ankle and foot reconstructive surgeon due to its unique requirement of simultaneously withstanding body weight and to provide sensory feedback. We share our experience of medial plantar artery perforator (MPAP) flap, which provides a robust sensate coverage to heel defects.Methods:Three-year retrospective study, which included soft-tissue injury to heel. All patients underwent MPAP flap for the coverage of the defect. Patients' demographic, mode of injury, defect size, flap size and survival, time to start weight bearing, return of protective sensations, and comparative 2-point discrimination with opposite heel were studied.Results:We studied 16 cases with heel soft-tissue injuries. Fifteen had motor vehicle accident, and 1 had chronic diabetic wound. Mean surface area of flap was 4 × 5 cm. Except 1 flap, 15 flaps had complete survival and provided reliable wound coverage with comparable normal sensation as on other foot.Conclusion:We suggest that MPAP flap, when available, is a good local tissue for heel wounds coverage.