Exploring Limb Salvage Options In Patients With Chronic Limb Ischemia

By John E. Aruny, MD, Peter Blume, DPM, Bauer Sumpio, MD, PhD, and Benjamin Buren, DPM

What Did The Angiogram Reveal?

   An angiogram revealed extensive tibial peroneal disease on the left limb with occlusion of all vessels to the mid-calf level. There was reconstitution in the anterior tibial that provided dominant flow to the foot and reconstitution of the dorsalis pedis artery. A MRI of the left foot revealed multiple areas of small abscesses associated with the ischemic ulcers but no evidence of osteomyelitis.    After the failed bypass, vascular surgeons were consulted and repeat vein mapping confirmed the absence of a usable vein conduit. With the history of aborted left lower extremity bypass, the multidisciplinary team planned for endovascular limb salvage with interventional radiology. Noninvasive vascular testing included TcPO2 of the left pretibial region (49 mmHg) and the left dorsum (30 mmHg).    A diagnostic angiogram prior to the aborted surgical procedure revealed a patent abdominal aorta, iliac arteries and left superficial femoral artery. The femoral bifurcation was intact. The above- and below-the-knee popliteal artery also was patent and without stenosis.    The posterior tibial artery was occluded at the level of the mid-calf. The peroneal artery was severely diseased. The anterior tibial artery had proximal, hemodynamically significant stenosis and a 30 mm long occluded segment at the level of the lower one-third of the calf. There was hemodynamically significant stenosis of the dorsalis pedis artery at and just below the level of the ankle joint.

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