Fig.

Timeline of patient with polyarteritis nodosa (PAN)-induced critical limb threatening ischemia (CLTI). She first presented with left acute limb ischemia with a mottled dusky foot and required emergent angioplasty to restore perfusion. Intraoperatively, angiographic evidence of “beading” with alternating dilatation and narrowing was observed (yellow arrow). Sequential angiography also revealed disease progression, with worsening distal tibial vessel patency and the last angiography demonstrating a “desert foot.” During her disease, she continued to deteriorate and experienced CLTI with tissue loss, requiring repeated angioplasty over a span of 10 months. In her third angioplasty, we used the MagicTouch, a sirolimus-coated percutaneous transluminal angioplasty catheter, on the anterior tibial artery (ATA), in the hope of arresting the vasculitis progression with the anti-inflammatory and immunosuppressive properties of sirolimus. Her foot healed within 4 months after sirolimus treatment, and she remained intervention free at 17 months and ulcer free at 13 months after her last treatment. Surveillance arterial occlusion ultrasound scans at 1, 6 and 12 months demonstrate that her ATA remained patent with no occlusion. She continued to have a strong dorsalis pedis pulse at her last follow-up at 17 months.