Featured Case Overview
65-year-old male with DM, HTN, CAD, and prior toe amputations presented with worsening R plantar ulcer over 3 months (image A). On exam, the right foot was cool to touch with monophasic doppler DP signal. The PT was absent. Arterial doppler showed patent femoropopliteal segment, elevated PSV in the AT, and densely calcified occlusion of the PT.
Right lower extremity angiogram was performed which confirmed chronic total occlusion of the distal PT as well as the lateral plantar artery (image B). Antegrade recanalization of the PT was successful, but the lateral plantar artery (angiosome of concern) could not be recanalized. The wire was parked in the medial plantar artery and a second wire was advanced retrograde through the occluded lateral plantar artery via the DP and arcuate artery (image C). The second wire was then captured with a snare at the femoral sheath.
Intraluminal position was confirmed with intravascular ultrasound. Atherectomy (Rotablator 1.75) with angioplasty was performed in the distal PT (image D). Prolonged angioplasty was performed in the lateral plantar artery and pedal arch (image E). Final angiogram showed in-line antegrade flow through the PT, lateral plantar, and arcuate arteries (images F,G).
The patient returned to clinic for 2 week post-operative visit and had doppler PT and DP signal in the right foot with interval progression of wound healing. At three month follow up the patient had near complete wound healing (image H) and had resumed walking.
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