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6 Arterial Revascularization
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197
• Finally, rotational atherectomy is often successful in this space as well.
6.20.3 Soft Plaque
Soft plaque and intraluminal thrombus represent
a unique challenge for even the most skilled operator. Distal embolization is a constant intraprocedural risk that only increases with passage of
each wire or device. Atherectomy in this scenario
can potentially increase this risk when the wrong
device is chosen.
• Devices that actively aspirate in addition to
plaque modication perform well in this
space.
• Rotarex combines an aggressive rotational
mechanism combined with the ability to
draw debris and soft plaque thrombus into an
attached receptacle. The benets increase
when the 8-Fr device is used, though its
application is limited by vessel diameter
[329].
• Jetstream works well here as well, but often
necessitates the use of distal embolic
protection.
• Laser may occasionally be applied here, especially if there is soft thrombus.
• Orbital atherectomy is often avoided here due
to the relative high risk of embolic
complications.
The decision to utilize any atherectomy device
in the popliteal artery should be made with careful
consideration. Kinetic forces make this vascular
bed challenging even for the most experienced
proceduralist. The choice of atherectomy device is
important to allow for efcient vessel preparation
which in turn lays the foundation for a durable
result. Many tools exist that can assess disease
morphology, but real-time ultrasound interrogation
can provide valuable detailed information and help
guide device selection. Based on ndings from
EVUS/IVUS, the skilled technician is better
equipped to tackle a wide variety of disease morphologies while limiting the risk of complications
like vessel occlusion or distal embolization.
ab cd e
Fig. 6.81 Diagnostic angiogram of the RLE showing
ISR/occlusion of the stent (a–c). There was primary anterior tibial artery runoff (d) with a reconstituted peroneal
artery at the level of the ankle which continues to the foot
as a hypertrophied posterior tibial artery and plantar
circulation
198
ab
I. Ali et al.
c
Fig. 6.82 IVUS catheter was used to delineate the ISR
contents which appears to be nonthrombotic (white arrow)
and more consistent with hyperplasia/soft plaque (a).
6.20.4 Case Example
Laser atherectomy was performed after placement of EPD
lter to catch potential debris (b). Scoring balloon angioplasty was then performed (c)
rior tibial artery and plantar circulation
(Fig.6.81d, e). IVUS catheter was used to delin-
6.20.4.1 Courtesy ofSreekumar
Madassery, MD
75-year-old patient with history of prior RLE
bare metal stenting for progressive claudication
18months prior. Patient presented with 3–4weeks
of worsening symptoms and subsequently developed rest pain. Diagnostic angiogram was done
showing ISR/occlusion of the stent (Fig.6.81a–c).
There was primary anterior tibial artery runoff to
the ankle with reconstituted peroneal artery that
continued to the foot as a hypertrophied poste-
eate the in-stent restenosis which appeared to be
nonthrombotic and more consistent with hyperplasia/soft plaque (Fig. 6.82a). Laser atherectomy was performed in the area and scoring
balloon angioplasty was then done (Fig.6.82b,
c). Drug-coated balloon angioplasty was then
done of the area. Percutaneous old balloon
angioplasty was done of the anterior tibial artery
and peroneal artery, with completion angiogram
demonstrating two-vessel runoff to the ankle with
improved perfusion to the forefoot (Fig.6.83).
6 Arterial Revascularization
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199
Fig. 6.83 Completion angiogram after scoring balloon
angioplasty and drug-coated balloon angioplasty of the
ISR and POBA of the peroneal and anterior tibial arteries
6.21 Below-the-Ankle
Atherectomy
demonstrated two-vessel runoff and adequate perfusion to
the forefoot
inherently small diameter of the pedal vessels in
general combined with the presence of extensive
calcication (particularly within the media and
BretWiechmann
common in patients with diabetes and chronic
kidney disease) makes establishing outow
The “last frontier” of endovascular intervention
in critical limb ischemia (CLI) involves the pedal
arch and plantar vessels. Maintenance of outow
through the lateral plantar, medial plantar, and
metatarsal branches may have signicant impact
on endovascular intervention in the tibial vessels
in this challenging patient group. Patients with
small artery disease (SAD) may indeed have poor
outcomes due to this lack of outow [330]. The
through the plantar vessels and/or establishing a
patent pedal arch critical in many CLI patients.
Percutaneous transluminal angioplasty (PTA)
is certainly the mainstay of endovascular therapy.
While adjunctive therapy such as atherectomy
and stenting in the femoropopliteal segment has
been frequently studied and in general is a widely
adopted practice among vascular interventionalists, the atherectomy and stenting options below
200
I. Ali et al.
the knee are limited and the evidence base to support its routine use is even more limited. While
there are large data sets supporting atherectomy
in the tibial vessels, including a recently published study of over 36,000 patients showing
excellent limb salvage rate and lower 4-year mortality with use of atherectomy in conjunction
with angioplasty, other studies have not produced
the same conclusion [331].
• The published data on use of atherectomy as
adjunctive therapy in the below ankle levels
are even more sparse.
• A PubMed search of “below-the-ankle atherectomy” yields only one single-center, retrospective study. In this study by Palena, 317
patients with diabetes and CLI underwent
orbital atherectomy plus drug-coated balloon
angioplasty. Patients were followed at 30days
and 6 months. The limb salvage rate was
100% at 6 months with an amputation-free
survival (AFS) of 50% at 6months. No major
amputations and six minor amputations were
noted at 6 months. Freedom from clinically
driven target lesion revascularization
(fCDTLR) was 100% at 30days and 91.7% at
six months. There were no major adverse cardiovascular or limb events (MACE/MALE)
and no evidence of perforation, dissection, or
embolization [332].
Considerations regarding use of atherectomy in
the below-the-ankle vessels revolve around deliverability and safety. The prole of certain FDAapproved atherectomy devices likely preclude
their delivery into these vessels that are typically
less than 3 mm. The lowest prole atherectomy
devices are the Nexcimer Laser System (Philips,
Amsterdam, Netherlands), the Auryon Laser
System (AngioDynamics, Latham, NY), the
Rotablator (Boston Scientic, Maple Grove, MN),
and the Stealth 360 orbital atherectomy system
(Cardiovascular Systems Inc., St. Paul, MN).
Beyond and perhaps more important than deliverability, however, is the safety of these devices in
this arterial segment; to date, peer- reviewed publi-
cations have not established their safety other than
the one small study noted above. It is worth noting
that these data were produced at a center that is
well known for its technical expertise and outstanding clinical outcomes. The applicability of
this approach on a broader scale and the reproducibility of its clinical efcacy remain uncertain.
Consideration of adjunctive atherectomy in
the below ankle/pedal vessels, as in the Palena
study, is typically performed in those patients in
whom crossing of a standard balloon catheter is
not successful. The inability to cross with a lowprole balloon suggests that the atherosclerotic
burden, particularly calcication, is extensive
which is known to be associated with poor angioplasty results due to recoil and dissection. Since
stenting through this area is neither recommended
nor proven, and with no approved scaffolds/stents
for this segment, optimal angioplasty is desired
and debulking these lesions may indeed make
intuitive sense.
When performing atherectomy in these vessels, methodical attention to detail is paramount.
Complications in this area can be devastating and
potentially limb-threatening.
• The idea of using one of these devices just
because it can be delivered to the target vessel
does not mean that it should be done.
• A slow cadence is used with laser systems.
• With orbital/rotational systems, low speed is
used. Without a denable endpoint, knowing
when to stop is critical.
• Negotiating these devices through the pedal
arch has resulted in well-known cases of get-
ting them stuck and requiring surgical
removal.
• Remembering that below-the-ankle atherec-
tomy is adjunctive therapy in order to opti-
mize angioplasty is the key to safety.
Much of endovascular treatment in the lower
extremity for peripheral arterial disease is proven
therapy and has repeatable, reproducible outcomes. The complexity of CLI patients with multiple comorbidities and a high short-term
6 Arterial Revascularization
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201
mortality rate makes this a very challenging population to treat in general. Enrolling patients in
CLI trials has proven to be difcult, and there-
• Therefore, while it may be intuitive, conven-
tional wisdom suggests it should only be per-
formed in unique situations with caution.
fore, obtaining denitive treatment strategies and
algorithms has been elusive. As a result, tremendous treatment variation exists, which further
6.21.1 Case Courtesy ofSreekumar
confounds the ability to develop consensus. This
is perhaps no more apparent than in the infrapopliteal vessels including the pedal/plantar vessels.
68-yo patient with ESRD, DM, CAD, and nonhealing wounds of the right second and third dig-
• There is extensive data to support the use of
PTA in the pedal/below ankle vessels due to
improved wound outcomes in those with a
patent pedal arch, but clear, denitive data
regarding the use of BTA atherectomy are yet
to be produced [333–335].
its with noninvasive imaging consistent with
popliteal and infrapopliteal signicant stenotic
disease. ABI on the RLE was 0.6, TBI of 0.3.
Procedural images as below (Figs. 6.84, 6.85,
6.86, and 6.87). Successful antegrade crossing of
calcied distal anterior tibial artery and dorsalis
ab c
Madassery, MD
Fig. 6.84 (a) Diagnostic angiogram demonstrated multi-
focal stenosis in the previously stented popliteal artery
(green arrow) and chronically occluded anterior tibial
artery (red arrow), with additional TP trunk disease. (b)
Additionally, there is peroneal artery stenosis at the level
of mid-calf (red arrow). (c) There is primarily posterior
tibial artery inow with an area of focal stenosis at the
bifurcation into plantar arteries (blue circle)
202
cd
ab
I. Ali et al.
Fig. 6.85 (a) After recanalization of the anterior tibial
artery, intraluminal injection demonstrated a small whisp
of a dorsalis pedis artery (red arrow). (b) There was initial
difculty traversing the pedal loop into the lateral plantar
artery. (c) DSA roadmap was done with groin sheath
injection which demonstrates the wire in lateral tarsal
branch (red arrow). (d) Wire was subsequently advanced
into the desired branch to traverse the lateral plantar artery
(blue arrow)
Fig. 6.86 Decision was made to perform orbital atherectomy of the DP into the pedal loop to increase
compliance
6 Arterial Revascularization
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ab cd
203
Fig. 6.87 Completion angiogram after plain and drugcoated balloon angioplasty of popliteal artery stenosis
shows three-vessel runoff both proximally (a, b) and dis-
pedis artery, through the Pedal loop and retrograde into the distal posterior tibial artery, thus
completing the loop. The loop was ideal to
increase perfusion after intervention to the
watershed areas of the digits and also to be able
to treat the focal distal posterior tibial artery stenosis (as below) with the same access. Postprocedure, after several weeks of continued
wound care, the digits were able to be healed
with debridement, and without amputation.
6.22 What Is My Endpoint
onAngiogram?
AbhishekKumar
An estimated 150,000 amputations occur due to
critical limb ischemia (CLI) in the United States
each year, with a large number of primary amputations being performed without diagnostic angiograms and attempts at revascularization [336]. In
2016, the American Heart Association/American
College of Cardiology released a Class I recommendation stating that an evaluation for revascularization options should be considered with
tally (c). Completion angiogram of the foot shows threevessel runoff at the ankle with now an intact pedal loop
(d)
imaging or an angiogram prior to amputation
[337]. More recently, the CLI global society pub-
lished an expert recommendation statement recommending use of digital subtraction angiography
(DSA) for evaluation of revascularization in
patients with CLI prior to amputation [338]. The
primary goal of revascularization is to improve
wound perfusion to allow healing. Equally important is tissue perfusion when an amputation is performed. While considerable debate still exists on
angiographic endpoints for endovascular therapy,
an understanding of angiographic patterns needed
for successful healing of amputation levels is necessary for the endovascular specialist.
1. Toe Amputation Versus Trans-Metatarsal
Amputation (TMA):
A wound blush (WB) on angiogram after
revascularization has been associated with
high rates of wound healing [339]. For healing of toe or partial ray amputations, it is usually necessary to have a patent pedal arch and
sufcient angiographic perfusion to the
wound. Figure6.88 illustrates a poorly healing partial ray amputation that healed after
successful tibial revascularization.
204
cd
I. Ali et al.
a
b
Fig. 6.88 (a) Status post-rst ray amputation with poor
wound healing, (b) digital subtraction angiography of the
below-knee vessels shows occlusion of anterior tibial and
posterior tibial arteries with single-vessel runoff to the
ankle, and (c) DSA at the level of the lower leg after endo-
vascular revascularization of the anterior tibial artery and
peroneal arteries shows improved supply to the foot. (d)
Delayed image from a foot angiogram after revascularization demonstrates a “wound blush” leading to adequate
wound healing
6 Arterial Revascularization
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Fig. 6.89 Digital subtraction angiogram showing wound
blush and adequate supply to a TMA
Healing at a TMA requires patency of one
or more infrapopliteal vessels with inline ow
to the foot. A patent pedal arch has been associated with higher rates of healing after
TMAs. When possible, a patent pedal arch is
desirable. Figure 6.89 illustrates an angiogram with ample supply to heal a TMA.
2. Symes:
A symes amputation or an ankle disarticu-
lation is an alternative to below-knee amputation. Advantages include a more comfortable
stump and a more functional gait. Studies
have shown that compared to BKA or AKA,
the symes amputation results in decreased
morbidity, early weight bearing without the
need for gait training, and a better gait
pattern.
A patent posterior tibial artery is necessary
for healing of a symes amputation.
3. Above-knee vs below-knee amputation (AKA
vs BKA).
A BKA is a transtibial amputation that
involves removing the foot, ankle joint, and
205
distal tibia and bula with related soft tissue
structures. It is preferred over an AKA because
it has better functional and long-term
outcomes. A popliteal artery pressure of 50
mmhg is considered adequate for healing a
BKA [340].
On angiography, occlusion of the distal
supercial femoral and popliteal artery is usually an indication that a BKA would be difcult to heal.
6.23 Orphan Heel
FarnazDadrass and SreekumarMadassery
6.23.1 Introduction
Heel ulcers are commonly seen in PAD patients
with diabetes. These are frequently the result of
trauma from constant pressure in the setting of
ischemia and/or neuropathy. Heel ischemia
results from disease of the posterior tibial and
peroneal arteries, with a subset of these patients
being diagnosed with orphan heel syndrome.
Orphan heel syndrome (OHS) is dened as an
ischemic heel ulcer seen with a compilation of
three disease processes that result in a characteristic pathological triad of:
1. Poorly controlled diabetes mellitus.
2. Chronic kidney disease/renal failure.
3. Occlusive PAD of the peroneal artery and
posterior tibial artery.
These ulcers are notoriously difcult to treat,
likely due to arterial insufciency, neuropathy,
high levels of inammation, decreased expression of various growth factors and increased
apoptosis [341]. This compartmentalization of
the blood ow to the heel becomes compromised,
resulting in ischemia. Orphan heel syndrome is
also difcult to diagnose as conventional measures can be misleading. The angiosome-based
model of revascularization is often used to target
the ischemic areas and has been shown to be
effective [342–344]. The calcaneal branch of the
206
ATA Angiosome PTA AngiosomePA Angiosome
I. Ali et al.
Medial
Plantar
Anterior
Tibial
Calcaneal
Branch
of PTA
Fig. 6.90 This gure is a representation of the angiosome concept. Reproduced from Iida etal. [343]. There
are six angiosomes total in the foot, broken down into different coloring perangiosome. The three source arteries
that feed the six angiosomes include the anterior tibial
artery (ATA), posterior tibial artery (PTA), and peroneal
artery (PA). The ATA supplies the dorsalis pedis artery
Lateral
Plantar
Calcaneal
Branch
of PA
(DPA), which supplies the dorsum of the foot. The PTA
has three branches: the medial plantar artery to the medial
sole of the foot, the lateral plantar artery to the lateral midfoot, and the forefoot calcaneal branch to the heel. The PA
branches off into the anterior perforating branch of the
PA, which supplies the lateral border of the ankle and the
calcaneal branch which supplies the outside of the heel
Peroneal
posterior tibial artery (PTA) supplies the heel.
The calcaneal branch of the peroneal artery (PA)
also supplies the heel (Fig.6.90).
Multiple collaterals exist between the tibial
arteries and their branches to supply all six angiosomes, as a protective measure should one of the
arteries become compromised. These arterial–
arterial connections are referred to as “choke vessels.” Occlusion of a main source artery frequently
changes angiosome locations for patients with
PAD [345]. Compensation with collateral vessels
allow for this process to take place in chronic
ischemic patients rather than acute limb patients
as “choke vessels” require four to ten days to
become patent after an ischemic event [345].
This results in the branches of main source arteries getting their supply from proximal arteries,
rather than the main source arteries themselves.
The reliance on collateral circulation over time
ultimately causes a mismatch between arterial
occlusion with wound angiosome location.
Ischemic ulceration of the heel can be understood in terms of the angiosome concept. As a
source vessel is compromised from calcication
secondary to atherosclerosis, the corresponding
skin at that angiosome can become ischemic and
necrotic. The compensatory mechanisms of pedal
choke vessels may be severely compromised by
atherosclerosis secondary to both DM and ESRD,
predisposing patients to the ischemic heel ulceration seen in the triad of OHS [345, 346].
6.23.2 Diagnosis
Orphan heel syndrome stems from occlusive
peripheral arterial disease of the PTA and PA,
both of which have branching calcaneal arteries
supplying blood to the heel. Once the compartmentalized ow to the heel becomes compromised, the heel can become ulcerated and
necrotic. The compensatory choke vessels are
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