This case is presented by Dr. Jack Hannallah, who was the managing physician at Modern Vascular in Tucson. In it, he details the case of an Arizona resident suffering from peripheral artery disease. A 74-year-old male with a history of type 2 DM, hypertension, hypercholesteremia, and former tobacco smoker (20 pack year history) presenting for evaluation of bilateral chronic non-healing ulcers on the plantar aspect of his great toes. Present for more than 3 years, the ulcers simply fail to fully heal. The patient is typically very active but ulcers are painful, limiting activities of daily livingg and ability to exercise. Recent radiographs demonstrated osteomyelitis of the left great toe as such focus was first placed on the left side. On physical exam, the patient has palpable pedal pulses the left great toe is red, tender, and swollen with an ulceration on the plantar aspect. Amputation was recommended given the chronicity and non-healing nature. The patient presented for a second opinion as a self-referral. Non-invasive imaging studies demonstrated left-sided TBI of 0.51 with multiphasic flow through the interrogated arteries of the left lower extremity. No evidence of hemodynamically significant stenosis was identified. Despite the lack of overt physical exam and ultrasound findings for arterial insufficiency a diagnostic angiogram was recommended to further evaluate the left lower extremity, given the chronicity and non-healing nature of the ulcer.

Non-invasive imaging
Chronic non-healing ulcer
Wound on the toe

Diagnostic Angiogram & IVUS Findings:

  • Focal 99% occlusion of the distal superficial femoral artery
  • Mild-moderate pedal-plantar loop disease
  • Otherwise, brisk flow through all 3 tibial arteries and into the foot
99% occlusion of the distal superficial femoral artery
Pedal Plantar Loop
Mild to Moderate Plantar Loop
Brisk Flow


  • Focal Jetstream atherectomy and angioplasty of the distal superficial femoral artery
  • Focused angioplasty of the pedal-plantar loop
Atherectomy 2.4/3.4 mm Jetstream
Artery Catheter
Angioplasty 6.0 x 100mm
Focused angioplasty graphic

Final Images:

  • Resolution of the focal stenoses with improved flow to the foot
Focal Stenoses
Improved flow
Final Angioplasty

Post Clinical Follow-up:

  • Images at about 10 weeks post intervention demonstrating resolution of the ulcer and associated cellulitis of the left great toe with radiographic evidence of significant improvement in the osteomyelitis. Patient was treated in the outpatient setting with PO antibiotics.
Toe Follow Up
Follow Up Healing Process
Follow Up Toe Photo