Featured Case Overview

The patient is a 51 year-old male with a past medical history significant for HTN, HLD, and DM (type 2) with associated neuropathy. He is an insulin dependent diabetic with his last A1c being 11.3. Patient denies a history of tobacco usage. He was referred to our clinic by his physician for a vascular consultation to evaluate a chronic left foot ulcer that developed osteomyelitis, resulting in multiple amputations.

Patient states that the foot ulcer first developed when he received a small cut on the bottom of his great toe. This wound was non-healing for the past three months, developing gangrene and osteomyelitis. He underwent a series of three amputations within a one-month span with the final amputation covering the great toe and metatarsal. After his final amputation procedure, he developed MRSA in his foot and has been on Vancomycin for the past month. Patient was referred to our clinic for angiogram to prevent further amputation of the left foot. Patient states that he never received an angiogram prior to his foot amputations. Upon interviewing the patient, he reports that he has a lack of sensation on his LLE since the amputation. He further complains of experiencing a burning sensation on the top of his feet whenever he sleeps. On his arterial duplex ultrasound, the patient had triphasic wave forms throughout in the bilateral lower extremities. His ABIs were also within normal limits.

On exam in the clinic, the patient had a dopplerable PT pulse with a 2+ DP pulse. Capillary refill was less than 3 seconds.

Despite the duplex arterial ultrasound appearing benign in nature, an angiogram was recommended due to the patient’s risk factors and prior amputation history. Diagnostically, the angiogram revealed no significant disease in the femor opopliteal region with an impressive three vessel runoff. At first glance, the angiographic findings seemed convincing enough to justify the rule out of a PAD diagnosis. However, visualization of the arterial flow in the ankle and foot region revealed occlusion of the lateral plantar artery with significant disease in the plantar loop. Using an antegrade approach, Rotablator atherectomy followed by prolonged balloon angioplasty was successfully performed in the lateral plantar artery with final angiogram demonstrating remarkable filling of this artery. There was also successful prolonged balloon angioplasty of the plantar loop with final angiogram demonstrating good flow through the pedal plantar loop.

Case Photos of Left Foot

Case Study Left Foot

Case Photos of Left Foot

Arterial Duplex Ultrasound Results

Arterial Duplex Ultrasound Results

Angiogram Pictures

Initial runoff images of fem-pop region

Fem Pop Region Runoff Image
Angiogram Runoff Image
Dr. Patel fem Pop

Initial runoff images of tibial arteries

Tibial Artery Runoff Image
Tibial Artery
Angiogram Image Tibial
Patel Case Study

Initial runoff images of the foot arteries

Occlusion of lateral plantar artery
Foot Arteries Angiogram
DP artery going into the 1st metatarsal branch with arterial blush to the amputation site
Initial foot runoff images

Images of intervention performed

Occluded Lateral Plantarartery

Multiple passes were made with a 1.25mm Rotablator to treat the occluded lateral plantarartery

Intervention performed
balloon catheter artery dilation

A 2.5 x 220mm balloon catheter was used to post dilate the arteries involved in the plantar loop.

Post Intervention Images

Post revascularization image reveals good filling of the lateral plantar artery
Post Intervention Image
Lateral plantar artery not seen because of competitive flow from the AT
Modern Vascular Case study post revascularization
Post Intervention Patel Case Study Image
Delayed subtracted rn shows cross filling of the segment of the lateral plantar artery from the PT and DP

Summary

In spite of the patient having a normal ABI, normal duplex arterial ultrasound, and palpable DP and PT pulses, the patient had disease limited to the inframalleolar region which is common in the diabetic population. These types of patients are the most difficult to evaluate clinically and b yultrasound as noted in this case, where the patient suffered from a wound on his great toe which ultimately led to amputation. If we did not proceed with the patient’s angiogram, in spite of having a normal vascular evaluation, the patient would have remained at risk of further amputation of the other digits on his left foot given that his lateral plantar artery was occluded with the plantar loop being significantly diseased. This is a perfect example of a case where instead of depending on a normal ultrasound and benign physical exam, the patient’s clinical status and risk factors must take precedence, justifying further investigation with an angiogram, especially in a patient with diabetes.

Meet the Doctor

Dr. Nikhil Patel Chief Medical Officer at Modern Vascular in Glendale, peripheral artery disease specialist

Dr. Nikhil Patel
Vascular Interventional Radiologist

Dr. Nikhil Patel is an interventional radiologist for Modern Vascular Glendale. Dr. Patel brings over 17 years of clinical, Interventional and leadership expertise. Dr. Patel is an author of the book Interventional Radiology Secrets and a co-founder of NANA Trust which provides free Vascular care to the under-served in Bangalore, India.

Learn more about Dr. Nikhil Patel

Dr. Nikhil Patel Modern Vascular Clinic