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
Arterial Duplex Ultrasound Results
Initial runoff images of fem-pop region
Initial runoff images of tibial arteries
Initial runoff images of the foot arteries
Images of intervention performed
Post Intervention Images
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.
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