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64 Interventional radiology and endovascular procedures
Clinical tip Re-entry devices
Re-entering the lumen can be
problematic in the presence of
heavy calcification, and devices
such as the Cordis Corporation
Outback® or the Medtronic
Pioneer® re-entry catheters,
which utilize an angled needle
to puncture back into the true
lumen, have been developed.
Both have been shown to be
safe and effective in managing
peripheral chronic occlusions
with a symptom-free interval of
12 months and no procedural or
post-procedural complications [4].
Expert comment
Stenting into the popliteal artery
can be problematic because of the
repeated external compression of
the stent when placed at flexion
points of the vessel, leading to
stent fracture. The IDEV Supera®
interwoven nitinol stent has
recently shown promising results
in the popliteal segment with no
stent fractures at one year in the
SUPERB trial or at two years in a
recent study [5] with significant
improvements in symptom
classification.
Clinical tip Antiplatelet
therapy
A recent study has shown that dual
antiplatelet therapy was associated
with reduced peri-interventional
platelet activation and a
reduced need for target lesion
revascularization [6].
Figure 7.3 DSA demonstrating in-line flow
down the SFA following stent placement.
Figure 7.4 DSA demonstrating in-line flow
down the SFA through to the popliteal artery and
tibioperoneal trunk following stent placement.
with contrast injection. The existing sheath was exchanged for a 6Fr sheath and
multiple 7mm self-expanding nitinol stents (Covidien EverFlex®) were placed with a
satisfactory angiographic result with no complications (Figures 7.3 and 7.4). Manual
compression to the puncture site followed.
A 300mg loading dose of clopidogrel was administered in recovery and dual
antiplatelet therapy with aspirin 75mg od and clopidogrel 75mg od prescribed after
the procedure. Follow-up at three months demonstrated improved symptoms and
ulcer healing, with a duplex examination showing stent patency with no in-stent
restenosis.
Discussion
The prognosis for patients presenting with critical limb ischaemia (CLI) is poor
not only for the limb but also for life. A year after diagnosis 25% of patients will
have died and 30% will have required a major amputation [7,8]. Vascular death had
65Case 7 SFA endoluminal bypass: critical limb ischaemia treatment
occurred in about 25% of patients ve years after bypass surgery and in nearly 50%
of patients after ten years, with the primary cause of death being vascular death [9].
The optimal treatment for patients presenting with CLI is revascularization, as
it is associated with a much greater perioperative mortality and morbidity than
amputation [10]. Extent of disease, morphology of the lesion(s), and distal run-off
combined with patient comorbidities determine the method and success of revascularization. TASC guidelines [3] currently recommend that patients presenting
with simple occlusive lesions (TASC A) are treated with endovascular therapy and
those presenting with advanced occlusive lesions (TASC D) are treated with surgical
bypass as a rst-line treatment. Endovascular procedures are only recommended for
patients who have a low healing potential following surgical revascularization with
TASC C lesions, and treatment recommendations for type B and type C lesions are
based on the patient’s comorbidities, fully informed patient preference, and the local
operator’s long-term success rates [3].
Endovascular therapy has shorter recovery times and lower morbidity and mortality rates than surgery. Techniques and technology continue to improve and expand,
making the treatment and outcomes for advanced disease more achievable by endovascular therapy. There are now many different percutaneous treatment options and
methods available for recanalization of long-segment SFA occlusions including reentry catheters, PTA with or without drug-eluting balloons, or self-expanding PTFE
and drug-eluting stents. Re-entry catheters also allow accurate re-entry into the lumen
following a subintimal approach with reduced risk of damaging healthy native vessel.
Recent developments in stent technology for complex femoropopliteal lesions have
been promising, with stenting shown to be superior to balloon angioplasty for long
lesions. The latest generation of stents, including stent grafts, are of increased length
(up to 20cm), have superior fracture resistance, allow complex long lesions to be treated endovascularly, and have comparable outcomes to articial femoropopliteal bypass
surgery. With the ever-increasing evolution of drug-eluting technology to further
reduce in-stent restenosis rates and increase stent patency, it may be just a matter of
time until TASC C and D lesions are primarily treated with endovascular techniques.
Evidence base Angioplasty
for the SFA
●
Technical and clinical success
>95% [11].
●
One-year patency 77% following
angioplasty of the stenosis and
65% following recanalization [3].
●
At three and five years, patency
rates decrease to 40–50% [3]
Sub-intimal angioplasty (SIA):
●
technical success reported to be
between 74% and 92% [12,13]
●
shown to be effective even with
unfavourable anatomy with up to
83% of limb salvage [14]
●
risk of vessel perforation is higher
for SIA than for conventional
PTA with an overall risk of 5–8%,
particularly in heavily calcified
vessels [15]
Evidence base DEB for the SFA
Drug-eluting balloons (DEBs) coated with paclitaxel are showing promising results, as demonstrated in
the following trials.
●
The Thunder trial (Paccocath–Cotavance technology) demonstrated that the use of paclitaxel-
coated angioplasty balloons during the treatment of femoropopliteal arterial disease was associated
with significant reductions in late lumen loss and target-lesion revascularization (TLR) (TLR at 24
months was 37% in standard balloon angioplasty versus 15% in the drug-coated balloon group)
[16].
●
The FemPac trial (Paccocath–Cotavance technology) demonstrated reduced restenosis in patients
undergoing angioplasty of femoropopliteal arteries (TLR at 18–24 months was 50% in the standard
balloon angioplasty versus 13% in the drug-coated balloon group) [17].
●
Levant 1 trial (Lutonix MoxyTM paclitaxel-coated balloon): the six-month average late lumen
loss, the trial’s primary end point, was 0.46mm in patients in the paclitaxel-coated balloon group
compared with 1.09mm for the conventional angioplasty control group (p=0.016). There was also
a non-significant trend in favour of the druft5>g-coated balloon for target lesion revascularization
(13% versus 22%).
●
The Pacifier trial (Medtronic In.Pact PacifierTM paclitaxel-coated balloon) demonstrated a lower rate
of late lumen loss (0.01mm) associated with the use of the drug-eluting balloon compared with
patients treated with an uncoated balloon (0.65mm). TLR at one year was 7.1% for the DEB versus
34.9% for the uncoated balloon.
66 Interventional radiology and endovascular procedures
Evidence base Surgery for
the SFA
The large UK Bypass versus
Angioplasty in Severe Ischaemia
of the Leg trial compared bypass
surgery with PTA/SIA for patients
with femoropopliteal disease and
severe limb ischaemia [25].
●
The primary outcome,
amputation-free survival after 6
months, did not differ between
groups.
●
There was no difference in all-
cause mortality or quality of life
at two years between the groups.
●
Surgical therapy was more
expensive than endovascular
treatment.
●
Re-intervention rates were
significantly higher in the
angioplasty group (28% versus
17%).
Evidence base Stents for the SFA
●
Late restenosis secondary to intimal hyperplasia remains the Achilles heel of stenting.
●
Four randomized trials (Absolute, Fast, Resilient, Scirocco II) for PTA versus stent have not shown a
convincing advantage in favour of stents for short femoropopliteal stenoses (<10cm).
●
New generation stents are designed to try and combat the problems of restenosis and stent
fracture.
●
67% one-year restenosis with angioplasty compared with 37% for nitinol stent deployment [18.]
●
New PTFE-lined stents have been designed to try and prevent in-stent restenosis through
ingrowth
●
Studies have demonstrated comparable patency rates over one, two, and 4 years between
PTFE-lined stents (Gore ViabahnTM) and surgical bypass with synthetic material (Dacron or PTFE)
[19–21] with significantly reduced hospital stay for the covered stent group (0.9 versus 3.1 days)
[19].
Evidence base DES for the SFA
●
Sirolimus-coated stents
●
The SIROCCO trials [22,23] compared sirolimus-coated stents with bare metal stents. They failed
to show a demonstrable efficacy of DESs compared with bare metal nitinol stents.
●
Everolimus-coated stents
●
The STRIDES trial suggested improved patency of everolimus-coated stents versus bare metal
stents at six months but this was not sustained at 12 months.
●
Paclitaxel-coated stents
●
Recent trials evaluating paclitaxel-eluting stents for above knee lesions demonstrated promising
anatomical and clinical results with 86% primary patency rate at 12 months [24]
●
Recently released but unpublished three-year data from the Zilver PTX (Cook Medical)
randomized controlled trial of paclitaxel-eluting stents for femoropopliteal disease have
shown 70.7% primary patency in the SFA at 36 months for patients treated with the Zilver PTX
paclitaxel-eluting stent. This compares with 49.1% patency for patients with percutaneous
transluminal angioplasty nd provisional bare metal stent placement in the study of 479
patients.
A final word from the expert
This case study highlights the increasing practice of treating TASC C and D lesions with
endovascular techniques. Unfortunately, traditionally many centres have poorly monitored
theses patients post procedure. Medium to long term patency of an ‘endoluminal bypass’
can be improved if a more robust regime of follow up is pursued with regular duplex
imaging and secondary interventions performed where required in the manner that most
vascular surgeons follow up and maintain patency of bypass grafts. If such an approach is
more widely adopted it is only a matter of time before endovascular therapy is considered
the primary treatment of choice.
References
1. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with
lower ext remity ischemia: revised version. J Vasc Surg 1997; 26(3): 517–38. Erratum. J
Vasc Su rg 2001; 33(4): 805.
2. Fontaine R, Kim M, Kieny R. [Surgical treatment of peripheral circulation disorders.] Helv
Chir Acta 1954; 21(5-6): 499–533 (in German).
3. Norgren L, Hiatt W, Dormandy J, et al. Inter-Society Consensus for the Management
of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surgery 2007; 33(Suppl 1):
S1–S75.
4. Smith M, Pappy R, Hennebry T. Re-entry devices in the treatment of peripheral chronic
occlusions. Tex Heart Inst J 2011; 38(4): 392–7.
5. Scheinert D, Grummt L, Piorkowski M, et al. A novel self-expanding interwoven nitinol
stent for complex femoropopliteal lesions: 24-month results of the SUPERA SFA registry. J
Endovasc Ther 2011; 18(6): 745–52.
6. Tepe G, Bantleon R, Brechtel K, et al. Management of peripheral arterial interventions
with mono or dual antiplatelet therapy—the MIRROR study: a randomized and doubleblinded clinical trial. Eur Radiol 2012; 22(9):1998–20 06.
7. Norgren L, Hiatt WR, Dormandy JA, et al., Inter-Society Consensus for the Management
of Peripheral Arterial Disease (TASC II). Available at: <www.tasc-2-pad.org> (accessed
October 2007).
8. Gottsater A. Managing risk factors for atherosclerosis in critical limb ischaemia. Eur J
Vasc Endovasc Surg 2006; 32(5): 478–83.
9. Van Hattum ES, Tangelder MJ, Lawson JA, et al. Long-term risk of vascular events after
peripheral bypass surgery. A cohort study. Thromb Haemost 2012; 108(3): 543–53.
10. Santilli JD, Santilli SM. Chronic critical limb ischemia: diagnosis, treatment and prognosis. Am Fam Physician 1999; 59(7): 1899–1908.
11. Muradin GS, Bosch JL, StijnenT, Hununk MG. Balloon dilation and stent implantation for
treatment of femoropopliteal arterial disease: meta-analysis. Radiology 2001; 221:137– 45.
12. Yilmaz S, Sindel T, Yegin A, et al. Subintimal angioplasty of long supercial femoral
artery occlusions. J Vasc Interv Radiol 2003; 14: 997–1010.
13. Flørenes T, Bay D, Sandbaek G, et al. Subintimal angioplasty in the treatment of patients
with intermittent claudication: long term results. Eur J Vasc Endovasc Surg 2004; 28:
645–50.
14. Kim JS, Kang TS, Ahn CM, et al. Efcacy of subintimal angioplasty/stent implantation
for long, multisegmental lower limb occlusive lesions in patients unsuitable for surgery. J
Endovasc Ther 2006; 13: 514–21.
15. Hayes PD, Chokkalingam A, Jones R, et al. Arterial perforation during infrainguinal
lower limb angioplasty does not worsen outcome: results from 1409 patients. J Endovasc
Ther 2002; 9: 422–7.
16. Tepe G, Zeller T, Albrecht T, et al. Local delivery of paclitaxel to inhibit restenosis during
angioplasty of the leg. N Engl J Med 2008; 358(7): 689–99.
17. Werk M, Langner S, Reinkensmeier B, et al. Inhibition of restenosis in femoropopliteal
arteries: paclitaxel-coated versus uncoated balloon: femoral paclitaxel randomized pilot
trial. Circulation 2008 23; 118(13): 1358–65.
18. Schillinger M, Sabeti S, Loewe C, et al. Balloon angioplasty versus implantation of nitinol
stents in the supercial femoral artery. N Engl J Med 2006; 354: 1879–88.
19. Kedora J, Hohmann S, Garrett W, et al. Randomized comparison of percutaneous
Viabahn stent grafts vs prosthetic femoral-popliteal bypass in the treatment of supercial
femoral arterial occlusive disease. J Vasc Surg 2007; 45: 10–16.
20. McQuade K, Gable D, Hohman S, et al. Randomized comparison of ePTFE/nitinol selfexpanding stent graft vs prosthetic femoral-popliteal bypass in the treatment of supercial femoral artery occlusive disease. J Vasc Surg 2009; 49(1): 109–16.
21. McQuade K, Gable D, et al. Four-year randomized prospective comparison of percutaneous ePTFE/nitinol self-expanding stent graft versus prosthetic femoral-popliteal bypass
in the treatment of supercial femoral artery occlusive disease. J Vasc Surg 2010; 52(3):
584–91.
67Case 7 SFA endoluminal bypass: critical limb ischaemia treatment
68 Interventional radiology and endovascular procedures
22. Duda SH, Bosiers M, Lammer J, et al. Drug-eluting and bare nitinol stents for the treatment of atherosclerotic lesions in the supercial femoral artery: long-term results from
the SIROCCO trial. J Endovasc Ther 2006; 13: 701–10.
23. Duda SH, Bosiers M, Lammer J, et al. Sirolimus-eluting versus bare nitinol stent for
obstr uctive supercial femoral ar tery disease: the SIROCCO II trial. J Vasc Interv Radiol
2005; 16: 331–8.
24. Dake MD, Scheinert D, Tepe G, et al; Zilver PTX Single-Arm Study Investigators. Nitinol
stents with polymer-free paclitaxel coating for lesions in the supercial femoral and
popliteal arteries above the knee: twelve-month safety and effectiveness results from the
Zilver PTX single-arm clinical study. J Endovasc Ther 2011; 18(5): 613–23.
25. Adam DJ, Beard JD, Cleveland T, et al. Bypass versus Angioplasty in Severe Ischaemia of
the Leg (BASIL): multicentre randomised controlled trial. Lancet 2005; 366: 1925–34.
CASE
8
Below the knee angioplasty: bare
versus drug-eluting stents
Stavros Spiliopoulos
Expert commentary Dimitrios Siablis
Case history
A 74-year old patient suffering from critical limb ischaemia (CLI) of the left lower
limb was scheduled to undergo angiographic evaluation of the peripheral arterial
bed and subsequent percutaneous endovascular revascularization attempt in the
interventional radiology department. The patient’s baseline symptomatology was
severe rest pain that was not responding to common analgesics, while physical
examination revealed dry gangrene of the left toe and stage 5 CLI according to the
Rutherford–Becket classication of peripheral arterial occlusive disease (PAOD). The
ankle–brachial index (ABI) at presentation was 0.60.
Learning point
CLI is a manifestation of PAOD that describes patients with typical chronic ischaemic rest pain or
with ischaemic skin lesions, either ulcers or gangrene (Fontaine III–IV and Rutherford–Becker 4–6
classifications). The diagnosis of CLI should be confirmed by the ABI and toe systolic pressure.
Ischaemic rest pain most commonly occurs with an ABI ≤50mmHg or toe pressure ≤30mmHg. In
the presence of ulcers or gangrene, CLI is suggested by an ABI <70mmHg or a toe systolic pressure
<50mmHg. However, currently there is no consensus regarding the vascular haemodynamic
parameters required to make the diagnosis of CLI. Moreover, ABI measurement can produce falsepositive outcomes in diabetic patients because the reduced vessel wall elasticity results in increased
ABI values. Finally, it should be noted that, by definition, the term CLI refers to patients with chronic
ischaemia (presence of symptoms for more than two weeks) [1].
The patient suffered from multiple comorbidities including ischaemic coronary
disease, chronic kidney failure under dialysis, and insulin-dependent diabetes mellitus and was judged unt for surgery by the vascular surgery department. The
decision to attempt a percutaneous endovascular approach was taken in a multidisciplinary meeting between interventional radiologists, vascular surgeons, and
nephrologists. No history of allergies, coagulation disorder, or other contraindication to percutaneous endovascular treatment was present. Baseline demographics
are reported in Table 8.1.
Pre-procedural Doppler examination revealed haemodynamically signicant
multilevel disease of the left supercial femoral artery (SFA) and below the knee
(BTK) vessels, but no signicant lesions were detected in the left iliac and common
femoral arteries.
70 Interventional radiology and endovascular procedures
Table 8.1 Patient’s baseline demographics and procedural details
Gender Male
Age (years) 74
Baseline Rutherford–Becket classification of PAOD 5
Baseline ankle–brachial index (ABI) 0.65
Body mass index (BMI) 22.5 (normal)
Comorbidities Coronary disease
Medication
Index lesion length 90mm
Stented lesion 94mm
Pre-procedural minimum vessel diameter 1.0mm
Post-procedural minimum vessel diameter 3.0mm
Remaining stenosis 0%
Clinical tip
Pre-procedural imaging prior to BTK interventions should provide accurate information about
the inflow and the infrapopliteal arterial status and includes multidetector computed tomography
angiography (MDCTA), contrast-enhanced magnetic resonance angiography (CEMRA), high-frequency
duplex ultrasound (HFDU), and digital subtractive angiography (DSA) [1–3]. Choosing which imaging
modality should be performed is case sensitive as each method presents specific advantages and
disadvantages. Nonetheless, appropriate procedural planning necessitates detailed pre-procedural
evaluation of the iliac arteries, the common femoral arteries, the SFA, the popliteal and infrapopliteal
arteries, and the distal foot vasculature.
Insulin-dependent diabetes mellitus
Hypercholesterolaemia
Chronic renal failure (dialysis)
Insulin, β-blockers, statins, clopidogrel
Expert comment
In patients who are not already
under antiplatelet therapy, dual
antiplatelet therapy with oral
clopidogrel (75mg/day) and aspirin
(100mg/day) is recommended at
least three days prior to infrapopliteal
intervention. In cases where this
three-day antiplatelet regiment
is not applied, a loading dose of
clopidogrel 300mg (12 hours before
the procedure) or clopidogrel 600mg
(2 hours before the procedure) can
be administered [4].
Pre-procedural laboratory examinations included baseline complete blood count,
platelets, and clotting prole (INR, prothrombin time, partial thromboplastin time).
The patient was already under antiplatelet therapy with clopidogrel 75mg 1 × 1 due
to coronary disease.
Based on the pre-procedural imaging a decision was taken to perform a direct
antegrade common femoral artery access as it allows easier catheter manoeuvres
as well as better pushability and trackability of all the endovascular materials,
especially when dealing with calcied distal occlusions. In our department local
anaesthesia and arterial puncture is obtained under ultrasound guidance as it
has been reported to produce a superior analgesic effect [5]. A 4Fr sheath was
positioned in order to perform a selective diagnostic DSA, which revealed multiple
signicant stenosis (up to 80%) of the left SFA. The sheath was upgraded to 6Fr
and the lesions were negotiated using a standard straight hydrophilic guidewire
and a 4Fr vertebral catheter which was subsequently used to perform an angiographic evaluation of the BTK arteries. Selective DSA revealed occlusions from the
origin of the anterior and posterior arteries, signicant tortuous stenosis (50–60%)
and one near-occlusion at the rst segment of the peroneal artery, which was the
only patent infrapopliteal vessel (Figure 8.1a). The arterial supply of the distal
foot was maintained by the distal peroneal collateral network (Figure 8.1e). The
peroneal artery demonstrated marked calcications of the vessel wall, typical of
(a) (b) (c)(d) (e)
Figure 8.1 (a) Baseline selective angiogram of the infrapopliteal arteries. Occlusion of the anterior
and posterior tibial arteries is noted. The peroneal artery is the only patent vessel to the distal foot. (b)
Magnified picture demonstrating a 50–60% stenosis (arrow) and a near-occlusion (distal arrow) at the
proximal segment of the peroneal artery. (c) DSA at an angle of 45° with respect to the previous DSA,
demonstrating areas of turbulent flow (double arrows) indicating marked atherosclerosis. (d) No other
significant lesions were detected in the mid and distal segments of the peroneal artery; (e) the arterial
supply of the distal foot was preserved by collaterals.
71Case 8 Below knee angioplasty: bare vs drug-eluting stents
Expert comment
Decreased contrast media
enhancement of a specific
infrapopliteal arterial segment
combined with decreased arterial
flow should be considered as a
radiological sign of flow-limiting
atherosclerotic disease and treated
appropriately.
patients who undergo dialysis, while the whole proximal peroneal segment gave
the impression of diffuse atherosclerotic disease in various runs performed at different angles (Figures 8.1b, c).
A decision was taken to perform direct overlapping stenting of the entire proximal peroneal segment using balloon-expandable sirolimus-eluting stents (CYPHER
Select©, Cordis, NJ, USA). A bolus dose of 5000IU of heparin was administered
intra-arterially and balloon angioplasty of the SFA was successfully performed.
The BTK lesions were crossed successively using a 0.014 inch guidewire (PT2®
Guide Wire, Boston Scientic, MA, USA). The rst stent (3 × 33mm) was deployed
in the proximal segment (Figure 8.2a). A check angiogram after the deployment
of the rst stent demonstrated elastic recoil of the previously pre-dilated nearocclusion. The remaining segment was treated using two DESs (2.75 × 33mm a nd
2.75 × 28mm), again in an overlapping manner (Figure 8.2b). At the end of the
procedure a straight arterial line of high antegrade ow down to the distal foot
was achieved (Figure 8.2c).
Quantitative-vessel analysis using integrated semi-automated software (Allura
Xper FD20, Philips, Amsterdam, The Netherlands) demonstrated 0% remaining stenosis at the end of the procedure, and the minimum diameter of the treated arterial
vessel increased from 1.0mm to 3.0mm after stenting. Arterial haemostasis was
obtained using an extra-luminal clip-based vascular closure device (StarClose®,
Abbott Vascular Devices, CA, USA) and no immediate or short-term complications
were noted. Dual antiplatelet therapy with aspirin 100mg 1 × 1 and clopidogrel 75mg
1 × 1 for six months followed by clopidogrel 75mg 1 × 1 for life was prescribed, and
72 Interventional radiology and endovascular procedures
(a) (b) (c)
Figure 8.2 Stenting procedure. (a) DSA image following the deployment of a 3 × 33mm DES in the
proximal segment of the lesion (double arrow). (b) A second 2.75 × 33mm DES was deployed across
the distal part of the lesion (double-headed arrow). The arterial segment between the two stents
(circled area) was subsequently covered with a 2.75 × 28mm DES. The lesion was post-dilated with a
3.5 × 80mm balloon. (c) Final check angiogram demonstrating a straight arterial flow with no evidence
of dissection or remaining stenosis along the treated area. Note the increased contrast enhancement
compared with Figure 1c.
the patient was discharged after overnight hospitalization. Post-procedural surgical
care was advised with clinical follow-up of regular visits at one and six weeks, six
and twelve months, and annually thereafter. Imaging follow-up included Doppler
ultrasound at three and six months, as well as annual DSA. After three months
follow-up the ABI gradually reached 0.8 which permitted the vascular surgeon to
safely perform surgical debridement to induce better wound healing. During the
three- and six-month follow-up periods there were no signs of SFA or peroneal
restenosis on Doppler ultrasound. The Rutherford–Becker classication at six and
twelve months follow-up improved from 5 to 2 (moderate claudication). Complete
wound healing was noted after twelve months follow-up (Figure 8.3). Follow-up
angiography after two years revealed a patent peroneal artery with no evidence of
in-stent restenosis (Figure 8.4). After three years clinical follow-up the patient is
alive and has not suffered any major or minor amputation, and there are no signs
of clinical relapse.
73Case 8 Below knee angioplasty: bare vs drug-eluting stents
(a) (b) (c)
Figure 8.3 Follow-up. (a) Magnified DSA image after two years follow-up shoeing a completely
patent peroneal artery with no evidence of in-stent restenosis. (b) Magnified single-exposure picture
demonstrating the stent’s integrity. Note the heavily calcified arterial wall, typical of dialysis patients. (c)
The peroneal artery is patent to the distal foot.
Baseline 6 months 12 months
(a)
Figure 8.4 Photographic documentation of wound status. (a) Pre-procedural gangrene. (b) Photo taken
six months after the procedure, following surgical debridement. (c) Complete wound healing after followup for one year.
(b) (c)
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