Abstract
A bidirectional approach is necessary for treating critical limb ischemia with complex, multiple lesions. We report an ultrasound-guided bidirectional puncture through an occluded vessel to treat an obstruction extending from the anterior tibial artery to the dorsal foot artery in a patient with toe gangrene and rest pain. This technique effectively restored arterial patency and is a promising approach for managing challenging critical limb ischemia occlusions.
Keywords: Critical limb ischemia, Endovascular treatment, Occluded vessel approach, Pull-through technique, Chronic total occlusion
Introduction
Critical limb ischemia (CLI) is the most advanced stage of peripheral arterial disease (PAD) characterized by ischemic rest pain, ulcers, and gangrene. According to a meta-analysis conducted in the United States, frequency of an ankle brachial index (ABI) of <0.90 in patients over 40 years of age was 5.8% [1]. There is a paucity of high-quality data on the epidemiology of CLI, and CLI accounts for less than 10% of all patients with PAD [2]. Patients with CLI are at high risk of mortality. Furthermore, a high rate of lower limb amputation has been reported in these patients, specifically in those with major tissue loss (Rutherford class 6), where the risk of limb loss is as high as 67.3% [1]. Although surgery and endovascular treatment have been reported to have no effect on mortality or reintervention rates, they improve wound healing and limb salvage [3]. Thus, revascularization is the first-line treatment for CLI. CLI is often associated with multilevel disease and usually requires tibial revascularization as well as treatment of inflow disease [4]. The use of endovascular treatment (EVT) for chronic total occlusion (CTO) in below-the-knee (BTK) lesions is typically challenging [5].
The introduction of retrograde approaches (such as distal puncture) has helped improve the success rate of EVT for such lesions; however, retrograde approaches for lesions with poor distal target vessels are extremely difficult [6]. The usual procedure is to puncture an open true lumen distal to the occluded vessel under fluoroscopic guidance with contrast or calcification; however, due care must be exercised because there is often no open artery available for puncture, and the difficulty of puncture may cause hematoma formation or lead to compartment syndrome due to failure of the puncture.
In this report, we present a case of ultrasound (US)-guided puncture of an occluded dorsal foot artery and treatment of a total anterior tibial artery (ATA) occlusion using a bidirectional approach with a pull-through technique.
Case report
Patient information
A 70-year-old man presented to our hospital with the chief complaint of rest pain in the second and fourth toes of the left foot, refractory ulcers, and gangrene (Fig. 1). He was a chronic smoker with a history of twenty pack-years. However, he had no history of hypertension, diabetes mellitus, coronary artery disease, cerebrovascular disease, or chronic kidney disease. Moreover, at the first visit, he was not on antiplatelet medication. There was no history of endovascular treatment.
Fig. 1.
Left foot showing intractable ulcers and gangrene of the second and fourth toes.
Clinical findings
Physical examination revealed pain, cyanosis, and ulceration of the left second toe. There were no signs of wound infection, and blood investigations showed no signs of elevated inflammatory response. The left femoral and popliteal arteries were palpable. The left dorsal foot artery and posterior tibial artery were not palpable. The left ABI was 0.65. The skin perfusion pressure (SPP) in the left foot was 33 mmHg dorsally and 26 mmHg on the plantar aspect.
Preoperative contrast-enhanced computed tomography (CT) showed left superficial femoral artery (SFA) stenosis and occlusion extending from the left ATA to the dorsal foot artery.
Therapeutic intervention
We immediately started dual antiplatelet therapy (aspirin, 100 mg/day; clopidogrel, 75 mg/day). To improve the healing of the left toe wound, the distal SFA with severe stenosis and the occluded ATA-dorsal foot artery were targeted for treatment. Because of the low SPP, delayed wound healing was expected. Owing to the patient's poor nutritional status, general condition, and physical examination as well as the very poor foot artery on CT, bypass surgery was considered difficult, and thus, we opted for EVT. EVT was attempted after 1 week of oral antiplatelet medication.
US-guided puncture was performed from the left common femoral artery using a Mini-access kit (Merit MAK®, Merit Medical Japan, Tokyo, Japan), and a 5-Fr sheath (Parent Select 5082®, Medikit, Tokyo, Japan) was inserted. The procedure was performed using a 4-Fr catheter (CXI®, COOK Medical Japan, Tokyo, Japan) and a 1.8-/2.6-Fr microcatheter (Prominent Raptor®, Tokai Medical Products, Aichi, Japan). Angiography revealed a short segmental occlusion in the middle of the left SFA and a long segmental occlusion from the left ATA to the dorsal pedal artery (Figs. 2A and B). A 6 mm × 12 cm drug-eluting stent (Eluvia®, Boston Scientific Japan, Tokyo, Japan) was placed in the severely stenosed left SFA via an antegrade approach.
Fig. 2.
Angiography of lower limb below-the-knee lesions. A long segmental occlusion from the left ATA (A, arrow) to the dorsal pedal artery is seen (B).
However, the guidewire could not pass the occluded ATA. Therefore, US-guided puncture of the occluded left dorsal pedal artery was attempted. A Mini-access kit (Merit MAK®, Merit Medical Japan, Tokyo, Japan) was used for retrograde direct puncture of the occluded dorsal pedal artery under US (Konica Minolta, Tokyo, Japan) guidance using a 15-MHz linear probe. US was used to delineate the dorsal pedal artery in the long axis direction and an anterior wall puncture was performed. The vessel was occluded and there was no reverse bleeding. A 0.018-inch guide wire (Halberd®, Asahi Intecc, Aichi, Japan) was advanced into the vessel lumen for US guidance (Fig. 3C, arrow). The sheath attached to the Mini-access kit was placed along a 0.018-inch guide wire.
Fig. 3.
Puncture and wiring of the occluded dorsalis pedis artery under ultrasound guidance (US images with schematic illustrations). US was used to delineate the dorsal pedal artery in the long axis view, and an anterior wall puncture was performed. A 0.018-inch guide wire (Halberd®, Asahi Intecc, Aichi, Japan) was advanced into the lumen of the vessel for ultrasound guidance (A, arrow). (B) Schematic illustration of puncture with US images. Subsequently, the central portion of the vessel was constantly visualized using US, ensuring continuous visibility of the guidewire within the field of view. The occluded segment was then traversed while maintaining constant monitoring of the guidewire in the US field. The guidewire (C, D, arrowhead) was then manipulated under US (C) and fluoroscopic guidance (D) and successfully rendezvoused with the antegrade system (C, D, arrow).
Subsequently, the central part of the vessel was consistently visualized using US, ensuring continuous visibility of the guidewire within the field of view. The occluded segment was then traversed with constant monitoring of the guidewire in the US field. The wire was then manipulated under fluoroscopic/US guidance and successfully rendezvoused with the antegrade system (Figs. 3C and D).
The ATA was dilated with a 3.0 mm × 10 cm and a 2.0 mm × 20 cm balloon catheter (Oceanus®, Medicos Hirata Inc., Osaka, Japan). The dorsal foot artery was dilated with a 1.5-2.0 mm × 21 cm balloon catheter (Nano cross Elite®, Medtronic, Tokyo, Japan) after removal of the distal sheath. Angiography confirmed the patency from the ATA (Fig. 4A) to the dorsal foot artery (Fig. 4B).
Fig. 4.
Final angiography and foot photograph. (A) Below-the-knee angiography; (B) Angiography of the foot; (C) Photograph of the foot. Angiography shows patency from the ATA (A) to the dorsal foot artery (B). Forefoot amputation resulted in excellent postoperative wound healing (C).
Outcome
Post-EVT, the ABI and SPP of the left lower extremity improved to 1.05 and 51/67 mmHg, respectively, with angiographic confirmation of blood flow to the dorsal foot artery via the ATA. Subsequent forefoot amputation resulted in excellent postoperative wound healing (Fig. 4C). The patient was discharged 1 month after surgery. The timeline from the first visit to discharge is shown in Fig. 5.
Fig. 5.
Timeline. Progress from admission to discharge.
Discussion
CLI is a clinical syndrome characterized by ischemic pain at rest or tissue loss (such as nonhealing ulcers or gangrene) related to peripheral artery disease. Patients with CLI are at high short-term risk of limb loss and cardiovascular events [5]. Without prompt revascularization, the incidence of limb amputation 1 year after diagnosis is approximately 25% [7,8]. As mentioned earlier, both surgery and endovascular treatment have been reported to be effective in wound healing and limb salvage; however, they do not affect mortality or reintervention rates [3]. Therefore, revascularization is the first-line treatment for CLI. Patients with CLI often have multiple stenoses and occlusive lesions, and traversing these lesions is typically challenging. Long occluded lesions often cause procedural failure.
The concept of angiosome focuses on improving the vascular condition and blood flow in vascular reconstruction and treatment. Particularly in patients with CLI, it is emphasized to prioritize the angiosome concept when considering methods and options for revascularization of below-knee lesions. EVT has been reported to be effective in improving wound healing in patients with CLI [9]. BTK, angiosome-directed angioplasty leads to greater wound healing [10], but failing this, any straight-line flow into the foot is pursued. Combined antegrade and retrograde approaches can increase the success rate in long total occlusions [6]. Therefore, the bidirectional approach has become an indispensable technique in EVT. However, in cases such as the present one, where the foot artery is weakened the target vessel (the dorsal foot artery) is occluded, conventional angiography/contrast-guided puncture is not possible and may make salvage difficult. The US-guided puncture of the occluded dorsal foot artery shown in the present case successfully traversed the long-obstructed ATA and dorsal foot artery, allowing angioplasty to be performed in accordance with the angiosome, thus avoiding major amputation.
US guidance during puncture is important because it enables visualization of the anterior wall of the target vessel and allows real-time confirmation of the entry of the needle tip into the vessel lumen, facilitating puncture even in occluded vessels. The foot artery is particularly amenable to visualization with US because of its proximity to the skin. The lack of radiation exposure or contrast media usage is another advantage of this approach. The target vessel is a small vessel sized 2-3 mm, and it is expected to be difficult to puncture. However, in the case of an occluded vessel, if the puncture fails, there are no bleeding complications, and repeat puncture is often possible.
Because the dorsal foot artery is a superficial vessel in close proximity to the tarsal bone, manual compression of the puncture site after the procedure is easier than for other lower extremity arteries. Previous studies have demonstrated the usefulness of IVUS-guided wiring for CTO lesions [[11], [12], [13]], and this technique allows for a seamless transition from puncture to wiring.
The limitation of the US-guided occluded foot artery approach is that it is not suitable for highly calcified lesions, which can make it difficult to delineate the vessel lumen with US. Especially in the proximal lower leg, delineating the target vessel is more challenging because of the depth. We consider it essential to wire with reference to angiographic findings and tramlines, emphasizing the importance of not strictly adhering to US guidance. We believe that US-guided puncture of the occluded foot artery is a potential option for distal puncture in EVT of the below-knee region for patients with CLI.
Conclusion
We report the successful use of a bidirectional approach in a patient with occlusion from the ATA to the dorsal foot artery. This involved puncturing the occluded dorsal pedal artery, resulting in the restoration of patency. US-guided puncture of the occluded pedal artery is a practical choice in cases where a bidirectional approach is necessary.
Author contributions
All authors provided substantial contributions to the manuscript and approved the final version of the article to be published.
Declaration of generative AI and AI-assisted technologies in the writing process
None.
Patient consent
Informed consent was obtained for the publication of this case report.
Footnotes
Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments: We thank Enago (www.enago.com) for the English language review. Funding: None.
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