The patient is a 64-year-old male with a history of hypertension, hyperlipidemia, stroke 1 year prior, and subsequent DVT with pulmonary embolism for which he has been on long-term coumadin. He is also on a statin and a beta-blocker. He was not on antiplatelet therapy.
Recently, he was diagnosed with venous insufficiency but has not been treated. He suffered RLE traumatic fractures 7 years prior and has no motor function below the knee and loss of R pedal sensation. He presented with moderate calf claudication and a chronic and progressing ulcer on the dorsum of his right second toe which he attributes to friction with poorly fitting shoes.
His doppler examination revealed tri-phasic waveforms from the CFA through the tibial arteries with bi-phasic waveforms in the dorsalis pedis arteries and a right toe-brachial index of 0.46 and left .056.
He underwent RLE angiography and intravascular ultrasound examination which revealed no significant PAD in the fem-pop segment or any of the tibial arteries. His pedal loop was severely compromised with occlusion of the lateral plantar artery and critical narrowing of the dorsalis pedis artery.
The distal dorsalis pedis artery could not be crossed successfully, but a collateral pedal loop from the lateral tarsal artery to the deep arch and lateral plantar artery was crossed and successfully treated with 2.0 mm angioplasty.
An AP magnification pedal angiogram demonstrated very good perfusion of the second toe with a notable paucity of digital branches to the 4th and 5th toes placing these digits at future risk.
At his six-month follow-up, the 2nd toe ulcer was completely healed.
Given the absence of supra-malleolar PAD, his claudication symptoms are most likely related to known venous insufficiency for which he remains awaiting treatment.
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