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CASE
11
Below the ankle angioplasty:
treatment rationale and access
techniques
Panagiotis Kitrou
Expert commentary Konstantinos Katsanos
Case history
A 70-year-old female patient underwent an urgent endovascular below-the-knee
revascularization procedure. The patient suffered from critical limb ischaemia (CLI)
and a previously placed common femoral artery–popliteal artery (CFA–POP) venous
bypass graft. The urgent referral form from the vascular surgeons team described
the condition as follows: ‘Patient with a left CFA–POP vein graft bypass and a single
vessel to the foot (peroneal artery). Ulcers don’t heal. Please attempt to improve
blood ow’.
Physical examination demonstrated an extensive foot ulcer located mainly at
the posterior aspect of the distal calf and the calcaneus and the posteromedial
aspect of the right foot (tissue loss, Rutherford stage 6). A previous angiogram,
performed in the context of an angioplasty for treatment of a proximal bypass
juxta-anastomotic stenosis, had shown that only the peroneal artery was patent to
the foot. The posterior tibial artery (PTA) was absent and the anterior tibial artery
(ATA) was occluded halfway to the foot. The patient was on clopidogrel 75mg/day
and aspirin 100mg/day.
Antegrade access to the left groin was achieved with a micropuncture kit
(S-MAK™; Merit Medical Systems, South Jordan, UT, USA). Images acquired conrmed
that the peroneal artery (PA) was the only patent vessel to the foot (Figures 11.1a,
b). Interestingly, a large collateral vessel of the PA was supplying the half-formed
plantar arch by interconnecting to the last 2–3mm of the salvaged PTA (Figure
11.1b). At the level of the trifurcation the origin of the PTA was absent (ush occlusion) and the ATA blocked at its proximal third (Figure 11.1c). Antegrade access
was established with a standard 4Fr vascular sheath. Although branches of the
half-formed plantar artery reached the foot ulcer of interest (Figure 11.1b), blood
supply was undoubtedly inadequate. The interventional plan was to re-establish
ow to the area of tissue loss through the PTA, which may be the direct line of
blood ow in accordance with the angiosome concept [1]. The plan was also to
attempt to re-open the ATA, if possible, in order to maximize reperfusion of the
pedal arch and the entire foot.
Retrograde access to the inframalleolar PTA was decided as no vessel stump was
visible at the tibioperoneal bifurcation (ush occlusion); this technique of a combined antegrade and retrograde approach is often described as the SAFARI angioplasty technique [2].
96 Interventional radiology and endovascular procedures
(a) (b) (c)
Figure 11.1 DSA showing the following: (a) the anterior tibial artery is patent to its proximal third; (b) the
peroneal artery is the only patent vessel to the foot; (c) a large collateral of the peroneal artery supplies
the plantar artery. The black arrow shows the small distal salvaged posterior tibial artery to which the
retrograde puncture was performed.
Learning point The angiosome concept
The angiosome concept divides the human body into three-dimensional tissue areas, which are
supplied with blood by specific arteries and drained by specific veins. Adjacent angiosomes are
connected by a mesh of collateral vessels. According to the angiosome concept the foot is divided
into five angiosomes supplied by the three tibial vessels.
●
Anterior tibial artery: when the ATA reaches the foot it becomes the dorsalis pedis artery (DPA)
which supplies the dorsum of the foot.
●
Posterior tibial artery (PTA): the PTA supplies the foot via three main branches. The medial calcaneal
artery (MCA) supplies the heel, the medial plantar artery (MPA) supplies the medial aspect of the
sole with the first toe and its interconnecting space, and the lateral plantar artery (LPA) supplies the
remaining, lateral aspect of the sole and the remaining e toes and their interconnecting spaces.
●
Peroneal artery: the PA supplies the foot via the lateral calcaneal artery (LCA) which supplies the
anterior and lateral part of the ankle and the lateral and plantar aspect of the heel.
The clinical application of the angiosome concept for below the knee disease is an attempt to
establish flow to an area of reversible ischaemia (foot ulcer) by direct revascularization of this area via
its source feed artery.
Learning point Chronic total occlusion (CTO) revascularization techniques to improve below
the ankle blood supply
●
SAFARI (subintimal arterial flossing with antegrade–retrograde intervention) is a CTO
revascularization technique in which a simultaneous antegrade (from above) and retrograde (from
below) approach is achieved for tibial and below the ankle vessels. The retrograde approach by
cutdown of the pedal arteries was first described by Iyer et al. in 1990 [3]. Access sites are the
distal PTA, the ATA, and the pedal and plantar arteries or collaterals as long as the lumen diameter
is appropriate. Retrograde puncture is always performed under ultrasound guidance. Usually no
(continued)
sheath is used (sheathless approach) which is why a micropuncture kit may be the best way to do it.
A low profile balloon is used to pass through the access and dilate the occlusion. The risks with this
technique are vessel perforation during puncture, vessel thrombosis, and inability to cross the lesion
retrogradely or even to puncture the vessel of interest. The main risk is damage of the pedal artery,
which could be used in the future for a surgical bypass.
●
The pedal–plantar loop is the technique by which a loop is created with a guidewire from one tibial
artery to the other via collaterals. The lateral plantar artery communicates with the dorsalis pedis
artery via the deep perforating artery.
●
Once the wire is looped to the contralateral vessel, a catheter is introduced in an antegrade manner,
via the same sheath used for the looped wire, towards the contralateral tibial vessel. The catheter
does not cross the lesion. The looped wire is directed to the catheter and then pulled with the help
of a retrieving device. A balloon can then be forwarded to the lesion in an antegrade manner.
97Case 11 Below the ankle angioplasty: treatment and access
The puncture site had to be located just above the connection of the peroneal collateral to the last part of the PTA shown in Figure 11.1b as this was the
only vessel supplying the foot and should not be jeopardized. Ultrasound-guided
puncture was performed using a micropuncture kit (S-MAK™; Merit Medical
Systems, South Jordan, UT, USA) and access was gained to the residual true
lumen of the distal PTA just above the connection with the peroneal collateral
(Figure 11.2).
Since no further true lumen was present, a Half Stiff (J-tipped) hydrophilic
guidewire (Terumo, Japan) was employed for retrograde subintimal recanalization.
Re-entry to the proximal true lumen occurred spontaneously at the tibio-peroneal
trunk, and access was secured by further advancing the wire in the distal part
Expert comment
The best way to perform a
retrograde puncture is with the
help of a micropuncture kit with
a short needle and a 0.014 inch
guidewire. An attempt to puncture
the only vessel supplying the foot
can have a disastrous result as, if
it fails, it may lead to acute limb
ischaemia and potential limb loss.
A retrograde puncture requires
familiarity with ultrasound- and/
or fluoroscopic-guided vessel
puncture techniques and should
generally be reserved for cases
with no other option following
a failed antegrade attempt at
recanalization.
(a) (b)
Figure 11.2 Retrograde puncture of the posterior tibial artery ((a) fluoroscopy; (b) DSA) showing the
puncture site as well as the wire being advanced in the subintimal plane along the tract of the posterior
tibial artery.
98 Interventional radiology and endovascular procedures
Expert comment
Despite the different theories
concerning ‘the right vessel to treat’
when dealing with the healing of
an ulcer, a vascular interventionist
should always bear in mind the
motto ‘treat as many vessels as
possible and safe to do’.
(a) (b)
Figure 11.3 (a) Wire from the retrograde puncture in the true lumen of the PTA and further advanced
into the SFA. The other wire from the antegrade puncture is directed to the ATA. (b) The wire from the
retrograde puncture (black arrow) is retrieved from the catheter, while the wire from the antegrade
puncture (white arrow) is forwarded into the catheter.
of the native supercial femoral artery (Figure 11.3a). A 4Fr straight catheter was
exchanged over the wire at the access point and advanced retrogradely up to the
tibial trifurcation. The Half Stiff wire was retracted and an 0.014 inch wire from the
antegrade access (PT2; Boston Scientic, Natick, MA, USA) was passed into the catheter from above (Figure 11.3b) in order to convert the angioplasty from retrograde
to antegrade. The 4Fr catheter was removed and the 0.014 inch wire was advanced
into the distal lateral plantar artery. Then the PTA was dilated with a long (3mm ×
150mm) low-prole balloon (Coyote; Boston Scientic, Natick, MA, USA) with a very
good angiographic result (Figure 11.4).
The completion angiogram shows brisk antegrade ow to the foot supplied from
both the posterior tibial and the peroneal artery, and the plantar branches are directly supplying the pedal arch. The patient was prescribed dual antiplatelet therapy for
six months. Duplex ultrasound surveillance three months later showed that both
vessels were patent without any signicant restenosis and there was progressive
healing of the wound.
99Case 11 Below the ankle angioplasty: treatment and access
(a) (b)
Figure 11.4 Completion angiogram: posterior tibial artery patent from the bifurcation (a) down to the
foot (b).
Discussion
Infra-popliteal angioplasty is now the method of choice for treating below the knee
lesions in CLI patients [4–6]. Furthermore, arterial occlusive disease in the setting of
CLI may be multilevel affecting even the distal tibial vessels in the region below the
ankle. Of interest, isolated inframalleolar lesions may be present in as many as 5%
of the cases [7]. Patency of the supercial femoral artery or proximal tibial vessels
may be compromised if treatment of the run-off vessels is not pursued [8]. As the
surgical approach to land a distal bypass anastomosis on vessels like the plantar or
the dorsalis pedis artery may be challenging, if not impossible, because of the atheromatous nature of these vessels or their complete absence, interventional techniques
have been developed to become a valid alternative treatment. However, evidence for
that hypothesis is not strong enough as only a small number of studies have been
published so far; nonetheless, they demonstrate that interventional treatment, either
intraluminal or subintimal, of below the ankle arteries is feasible and safe [7,9–13].
Additionally, the applicability of new technologies such as drug-eluting stents, selfexpandable drug-eluting stents, or drug-coated balloons and their possible superiority over ‘traditional’ angioplasty remains to be investigated and proved.
The calibre of small vessels is the main reason for the delay in focus on the infra-
inguinal region, which in turn explains the lack of evidence. So far, below ankle
100 Interventional radiology and endovascular procedures
angioplasty has been reserved for the exceptional treatment of complications like
distal embolism or dissection [13–15]. Only recently has the introduction of dedicated devices and low-prole balloons allowed infra-malleolar endovascular treatment
and the development of new access techniques such as SAFARI, the pedal–plantar loop, and even the trans-collateral retrograde approach provided that the vessel
diameter is adequate.
Expert comment
When manoeuvring with catheters and wires in the fine vessels of the delicate infra-malleolar
region, the operator should be aware of the anatomical changes following foot movement. As the
plantar and dorsal flexion of the ankle joint has the ability of angulation of up to 90° the soft tissue
anatomical structures and the vessels also comply with this movement. Therefore, as well as fixing the
foot in the appropriate anatomical position depending on the vessel treated (i.e. plantar flexion for
the dorsalis pedis artery and dorsal flexion for the plantar artery), one should also avoid stenting these
areas.
In 1987, Taylor and Palmer [1] published their work on angiosomes (Figure 11.5).
Since then, many elds of medicine adapted their treatment strategies by taking this
approach into consideration. Nevertheless, there are only few studies investigating
whether the angiosome concept is of use when planning the vascular treatment of
a foot in order to improve ulcer healing or limb salvage rates [16–21]. The question
is whether a direct revascularization, which establishes a straight vascular line to
LCA
DPA
(a)
DPA
MCA
MPA
MPA
(b) (c)
Figure 11.5 Vascular distribution of the foot according to the angiosome concept: (a) lateral view; (b)
medial view; (c) plantar view. LCA, lateral calcaneal artery; DPA, dorsalis pedis artery: MPA, medial plantar
artery; MCA, medial calcaneal aretry: LPA, lateral plantar artery.
MPA
MPA
LPA
MPA
MCA
LCA
the ulcer site, would give a higher ulcer healing rate (or lower healing failure) than
an indirect revascularization, which treats a tibial vessel that does not supply the
angiosome of the ulcer.
A final word from the expert
In the case presented here, the ulcerated region was fed by collaterals from the PA and not
by the main ‘direct’ feeding vessel of the corresponding angiosome, which is the PTA. The
improvement of the ulcer at three months suggests that the angiosome directed healing
strategy followed may be beneficial. As noted, support for this theory is based mainly on
retrospective data collection. Alternatively, there is evidence of ulcer healing in the presence
of a patent arch with functioning collaterals and no patent direct flow line [22–24]. Everyday
practice lies between these two theories. The interventionist attempts to improve blood
supply to the foot using the maximum number of vessels and in the safest way given the
individual circumstances. However, as these patients usually present with only one patent
vessel, which is frequently diseased, an attempt to repair even this single vessel may be
catastrophic, i.e. in the case of failure acute ischaemia may occur and it may be necessary
to amputate the limb Therefore the benefits of such an interventional procedure should
be balanced against its high risks and discussed with the patient beforehand. In conclusion,
patent infra-malleolar vessels not only establish blood flow to the foot but also improve
the patency of treated SFA or tibial vessels. An interventionist should always aim for the
maximum number of patent vessels to the foot, ideally including the one supplying the
area of tissue loss, provided that it is deemed safe to pursue their recanalization,. The
new techniques available for this purpose should be applied wisely and after taking into
consideration not only the intended benefits but also the associated risks.
101Case 11 Below the ankle angioplasty: treatment and access
References
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study and clinical applications. Br J Plast Surg 1987; 40(2): 113–41.
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SECTION 2
Venous procedures
Case 12 Dialysis access at risk: balloons or stent grafts?
Case 13 Phlegmasia cerulea dolens: percutaneous treatment
Case 14 IVC filters and anticoagulation
Case 15 TIPS and TIPS revision for Budd–Chiari patients
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