Medial-to-lateral plantar loop technique for retrograde transcollateral recanalization of the lateral plantar artery in patients with type 3 plantar arch.

A 89-year-old male presented with severe untreatable pain and ischemic non-healing ulcer in the left forefoot. The pre-procedural angiograms showed multiple stenosis of the superficial femoral and popliteal arteries, occlusion of anterior tibial artery, tibio-peroneal trunk (TTP) and distal posterior tibial artery (PTA), stenosis of the peroneal artery, and the patency of the medial plantar artery (MPA) as a single pedal artery, with very poor perfusion of the lateral aspect of the forefoot. The TTP and PTA were recanalized, and balloon angioplasty of superficial femoral artery and popliteal artery and peroneal artery was carried out. After unsuccessful antegrade attempts, the lateral plantar artery (LPA) was retrogradely recanalized performing the medial-to-lateral plantar loop, navigating from the deep branch of MPA to the plantar arch and reentering back in the common plantar artery through the LPA. Balloon angioplasty of LPA was performed though the retrograde and antegrade route. When the MPA is the single pedal artery, and the antegrade recanalization of the dorsalis pedis artery (DPA) and the LPA is not possible, the medial-to-lateral plantar loop is a feasible technique to recanalize the LPA retrogradely through the plantar arch.

Retrograde Deep Femoral Artery Access as Bailout Technique to Rescue Unexpected Ostial Occlusion during Antegrade Superficial Femoral Artery Recanalization.

We report a case of deep femoral artery (DFA) retrograde access for recanalization of an accidental ostial occlusion complicating an antegrade-retrograde superficial femoral artery (SFA) procedure. A 77-year-old man with chronic limb-threatening ischemia of the right lower limb was submitted to a duplex ultrasound that showed a heavy calcified SFA chronic total occlusion. During antegrade and retrograde attempts to cross the SFA obstruction, a control angiogram unexpectedly showed the ostial occlusion of the DFA. Several antegrade attempts to cross the DFA occlusion with various guidewires and catheters were unsuccessfully made. Retrograde access was achieved by direct puncture of the DFA distally to the first perforating artery. With sheathless approach, the occlusion was crossed, the retrograde guidewire was externalized through the femoral sheath, and the balloon angioplasty was then performed antegradely. The SFA recanalization was interrupted because of patient discomfort. The patient had an uncomplicated recovery, with immediate resolution of rest pain probably because of the resolution of the underestimated DFA stenosis. The retrograde DFA access is a useful bailout technique in case of accidental ostial occlusion of the DFA.

Arteriovenous Fistula of the Peroneal Artery Complicating a Retrograde Access: Successful Endovascular Treatment with Covered Stent Implantation.

An 80-year-old woman developed a recurrent chronic limb-threatening ischemia of the right lower limb after a popliteal artery (PA) recanalization with retrograde puncture of the peroneal artery (PR). The angiography showed the PA restenosis and an arteriovenous fistula (AVF) at the previous peroneal retrograde access site. After the PA angioplasty, the AVF was identified through selective contrast injections in multiple projections. A coronary balloon-expandable covered stent was deployed at the AVF site with complete resolution of the AVF. The final angiography demonstrated the patency of PA and PR with complete resolution of the AVF. The patient was discharged without complications, with regression of rest pain. The foot lesion healed within 2 months.

Femoral Balloon-Oriented Puncture for True Lumen Reentry in the Common Femoral Artery After Subintimal Retrograde Recanalization of Superficial Femoral Artery Ostial Occlusion: The FORLEE Technique.

Purpose: To report a new technique to reenter the common femoral artery (CFA) true lumen after retrograde recanalization of a superficial femoral artery (SFA) with flush ostial occlusion. Technique: The technique is demonstrated in a 76-year-old woman with critical limb ischemia previously submitted to several surgical revascularizations. A duplex ultrasound showed flush ostial occlusion of the SFA and patency of the anterior tibial artery at the ankle as the sole outflow vessel. After unsuccessful antegrade attempts to recanalize the SFA, a retrograde guidewire was advanced subintimally up to the CFA, without gaining reentry. A balloon catheter was inflated in the subintimal plane across the SFA ostial occlusion. Antegrade access to the distal CFA was achieved with a 20-G needle, which was used to puncture the balloon. A guidewire was advanced into the balloon and pushed forward while the collapsed balloon was pulled back to the mid SFA. The antegrade guidewire was externalized through a retrograde catheter, which was pushed in the CFA true lumen. A retrograde guidewire was advanced and externalized through the femoral sheath, establishing a flossing wire. The procedure was completed in antegrade fashion. Conclusion: The FORLEE technique is a cost-effective option to gain the CFA true lumen after subintimal retrograde recanalization of an ostial SFA occlusion.

Limb salvage in Charcot foot and ankle osteomyelitis: combined use single stage/double stage of arthrodesis and external fixation.

BACKGROUND: Charcot neuroarthropathy of the foot/ankle is a devastating complication of diabetes. Along with neuroarthropathy, osteomyelitis can occur which can result in amputation. This prospective study evaluated a limb salvage procedure as an alternative to amputation through surgical treatment of osteomyelitis of the midfoot or the ankle and stabilization with external fixation. MATERIALS AND METHODS: Forty-five patients with Charcot arthropathy and osteomyelitis underwent debridement and attempted fusion with an external fixator. Chart and radiograph review was performed to assess the success of the fusion and eradication of infection. RESULTS: Out of 45 patients, 39 patients healed using emergent surgery to drain an acute manifestation of the infection while maintaining the fixation for an average of 25.7 weeks. Two patients were treated with intramedullary nail in a subsequent surgical procedure. In four patients, the infection could not be controlled, therefore a major amputation was carried out. CONCLUSION: For select patients, external fixation proved to be a reasonable alternative to below-knee amputation.

Substent Anchor Technique for Recanalisation of a Full Metal Jacket Femoropopliteal In-Stent Occlusion.

PURPOSE: To report the endovascular treatment of a full metal jacket (FMJ) femoropopliteal chronic total occlusion (CTO) using a new ancillary retrograde technique. CASE REPORT: An 80 year old woman with type 2 diabetes presented to the Diabetic Foot Clinic with critical limb ischaemia with tissue loss in the right leg. Her comorbidities included coronary artery disease, morbid obesity, hypertension, dyslipidaemia, and active smoking habit. The patient had been treated at another hospital by femoropopliteal FMJ stenting six years before this presentation. The duplex ultrasound showed a full length in-stent re-occlusion. An antegrade recanalisation was attempted via contralateral femoral access, but was unsuccessful. An ultrasound guided retrograde puncture of the popliteal artery in the P2 segment was performed very close to the distal occluded stent. A 0.018 guidewire was pushed in the substent plane, functioning as an anchor to achieve a stable system. The FMJ was then retrogradely recanalised with a second guidewire. The procedure was completed by antegrade angioplasty with drug coated balloons. CONCLUSION: The substent anchor technique can help to achieve stability even if close to the occluded stents, and spares the distal landing zone for surgical revascularisation if the endovascular approach fails. This technique could be useful in retrograde treatment of long in-stent CTO.

What's next after optimal infrapopliteal angioplasty? Clinical and ultrasonographic results of a prospective single-center study.

PURPOSE: To evaluate arterial patency and factors influencing outcomes after successful tibial artery angioplasty in patients with critical limb ischemia (CLI). METHODS: From January 2005 to August 2007, a prospective single-center study was conducted involving 80 CLI patients (56 men; mean age 71.7+/-8.8 years) who underwent successful tibial artery angioplasty (<30% residual stenosis) in 87 limbs. Eighty (92%) limbs showed ischemic ulcers or gangrene at baseline. In two thirds, a more proximal lesion was treated, and a secondary stent was implanted in 14 (16%). Follow-up included clinical examination for wound healing (WH), limb salvage (LS), and duplex-documented target vessel patency or restenosis at discharge and at 1, 3, 6, 9, 12, 18, and then every 6 months. Patency rates, WH, and LS were assessed with the Kaplan-Meier method, and factors influencing these outcomes were analyzed using Cox proportional hazards models. RESULTS: Mean follow-up was 10.9 months (range 2 days - 29 months). At 12 months, the primary and assisted primary patency rates were 37.9% and 71.2%, respectively. Restenosis was significantly correlated with smoking (HR 3.58, 95% CI 1.15 to 11.18; p = 0.02), infected ulcers (HR 2.04, 95% CI 1.02 to 4.09; p = 0.04), and posterior tibial artery angioplasty (HR 3.76, 95% CI 1.59 to 8.87; p = 0.003). Rates of LS and WH at 12 months were 92.7% and 74.9%, respectively. Peroneal angioplasty was significantly correlated with WH (HR 1.83, 95% CI 1.04 to 3.25; p = 0.03), and wound healing increased with classes of age (HR 1.60, 95% CI 1.07 to 2.39; p = 0.02). CONCLUSION: One-year restenosis after optimal tibial artery angioplasty is significant and positively correlated with smoking, infection of trophic lesions, and posterior tibial artery angioplasty. Close ultrasound surveillance provides good limb salvage after optimal infrapopliteal angioplasty in patients with CLI.