Featured Case Overview
58-year-old former smoker with a past medical history of DMII, HTN, HLD, and hx of PE. Referred from a podiatrist for worsening foot pain, poor pedal pulses, and plans to perform a tenotomy on the left second toe. The patient has a history of toe ulcerations and prior partial right 2nd toe amputation for a non-healing ulcer. The patient presented To moderate vascular with complaints of constant numbness in bilateral feet, worsening pain in the toes, and frequent slow-healing blisters of the feet. The symptoms have been progressing over the previous 4 years.
Physical examination demonstrated onychomycosis bilaterally with dystrophic toenails, hyperpigmentation of both feet, small, shallow ulceration of the left second toe, and capillary refill greater than 3 seconds. Evaluation of peripheral pulses demonstrated barely detectable or slightly diminished DP and PT pulses bilaterally. ABIs on were right 1.9, left 1.2, TBI’s on were right 0.99, left 0.85.
Left lower extremity arteriography was performed, which demonstrated wide patency of the femoral-popliteal and tibial arteries. In the foot, the lateral plantar and dorsalis pedis arteries were chronically occluded, and there was no continuous arch. The medial plantar artery was hypertrophied and served as the dominant runoff vessel to the foot. Using endovascular techniques the chronically occluded dorsalis pedis artery was recanalized and the pedal arch was reconstructed with the formation of a pedal loop between the DP and medial plantar arteries. Laser atherectomy of the dorsalis pedis and distal medial plantar arteries was performed, with subsequent angioplasty of these vessels as well as the newly formed pedal loop.
Two weeks after the procedure the patient-related markedly improved symptoms, with increased sensation in the left foot with no pain. He is scheduled for left second toe tenotomy, as well as right leg arteriography for evaluation and probable treatment of his chronic right foot numbness and toe pain.
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