Collateral circulation between angiosomes in the feet of diabetic patients

Objectives The main factor in the healing of foot ulcers in diabetic patients is adequate perfusion. There is no consensus on whether direct or indirect revascularization is more effective in leg revascularization. At the centre of that debate, there is a disagreement about whether collateral circulation is sufficient or not. Our aim is to evaluate collateral circulation activity between angiosomes in the feet of diabetic patients by evaluating the level of occlusion in leg arteries and comparing the angiosome regions that have necrosis. Methods The study included 61 patients. All had undergone CT angiography to the lower extremity prior to any revascularization of the leg arteries between September 2014 and September 2016. Stenosis was evaluated on the anterior tibial artery, the posterior tibial artery and the peroneal artery up to the level of the ankle. The opening of the vessel wall at the narrowest part of the vessel was determined as a percentage. The areas with necrosis were determined according to the angiosomes of the posterior tibial artery, anterior tibial artery and peroneal artery vessels. Results Necrosis of the foot was most common in the posterior tibial artery angiosome. Necrosis in the posterior tibial artery angiosome was independent of the level of posterior tibial artery occlusion; however, it was associated with the occlusion of the anterior tibial artery ( p < 0.05). It was found that anterior tibial artery occlusion over 15% resulted in necrosis in the posterior tibial artery angiosome. Conclusions Collateral circulation between the anterior tibial artery and posterior tibial artery is active and there is almost always occlusion in the posterior tibial artery branches. The posterior tibial artery angiosome is fed by the collateral arteries of the anterior tibial artery even if there is no occlusion of posterior tibial artery at the level of the leg, so indirect revascularization on the anterior tibial artery is sufficient to provide foot circulation.

Republished: Nitinol clip distal migration and resultant popliteo-tibial artery occlusion complicating access closure by the StarClose SE vascular closure system

Lower extremity ischemia following deployment of a vascular closure device for access site closure after a transfemoral endovascular procedure rarely occurs. A 68-year-old woman diagnosed with subarachnoid hemorrhage due to a ruptured anterior communicating aneurysm was treated by endovascular coil embolization. The StarClose SE device was deployed for right femoral arteriotomy closure. After 2 days, critical ischemia occurred on her right lower leg due to total occlusion of the popliteo-tibial artery. Emergent surgical embolectomy was performed and the nitinol clip of the StarClose device was captured in the lumen of the tibioperoneal trunk. Although StarClose is an extravascular closure system, intravascular deployment, distal migration, and resultant critical limb ischemia can occur.

Retrograde transpedale recanalisation of tibial artery occlusion

Increasing prevalence of diabetes mellitus is frequently associated with complex tibioperoneal obstructive disease and a high rate of amputations. Endovascular therapy of arteries below the knee has emerged as a promising revascularization technique for patients with critical limb ischemia. Recent advances in catheter technology applied below the knee will increase the demand for and acceptance of minimally invasive therapy. However, when employing standard approaches, PTA of below-the-knee arteries may fail in up to 20% of cases. In the present article, we report an interventional strategy using a retrograde transpedal angioplasty approach, which was successfully applied in a 73 year old male diabetic patient with critical lower limb ischemia and a challenging occlusion of the anterior tibial and dorsalis pedis artery. This technique may probably increase success rates of PTA in cases with total occlusion of below-the-knee arteries, especially those without proximal occlusion.