PMC9818044_01
Preoperative image of right lower extremity showing necrotic ulcers in the leg and toes.
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F1
Physical examination revealed ulcers in the right leg and toes with absent pedal pulse (Figure 1).
Preoperative (pre-op) imaging with computerized tomographic angiography (CTA) and magnetic resonance imaging (MRI). CTA shows an occluded popliteal artery isodense to the reference muscle tissues (A). MRI shows a lesion that is hypointense in T2-weighted (B)and isointense in ultrashort echo time (C), characteristic of dense collagen.
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F2
CTA of the lower extremities revealed a long segment of noncalcified high-grade stenosis to occlusive disease in the superficial femoral artery (SFA) (Figure 2 A), with a three-vessel runoff in the calf. The patient was also scanned with a 3T MRI as part of a research protocol that depicted a hypointense T2W signal (Figure 2 B) and an isointense UTE signal (Figure 2 C), which is characteristic of dense collagen.
Intraoperative angiograms. (A) Failed attempt to recanalize occlusion (black arrow) with subintimal dissection (white arrows). (B) Flow-limiting dissection of the femoral artery due to multiple recanalization attempts. (C) Successful restoration of flow after femoropopliteal bypass.
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F3
Several attempts to subsequently cross the SFA lesion were unsuccessful (Figure 3 A) and led to a flow-limiting dissection (Figure 3 B) that was successfully treated by balloon angioplasty. Completion angiogram demonstrated patent bypass with no kinking and a three-vessel runoff into the foot (Figure 3 C).
Histology of popliteal artery lesion showing dense collagen composition of atheromatous plaque.
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F4
The popliteal artery was harvested for histological analysis and confirmed the presence of dense collagen in the plaque (Figure 4).