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CTA imaging of below knee vessels.
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An arterial duplex ultrasound and CT Angiogram (Fig. 1) found that the anterior tibial artery (ATA), which was the target angiosome vessel, was occluded.
(a) The below knee angiogram shows that the ATA is stenotic proximally and occluded at mid segment (long arrow). Peroneal artery is the main run off vessel. Distal ATA is reconstituted by the peroneal artery (short arrow). (b) Open approach to view distal anterior tibial artery. (c) Transpedal puncture kit and passage of 0.018" V18 wire.
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The angiographic images of the distal posterior tibial artery (PTA) (Fig. 2) were suggestive of underlying Buerger's disease. As the patient had preoperatively undergone a popliteal nerve block, the skin overlying the DPA was cut longitudinally for 3 cm (Fig. 2b). A V18 (0.018") (Boston Scientific, MA, USA) wire (Fig. 2c) was used to traverse the occluded point of the distal ATA supported with a 2.6 Fr angled CXI (Cook, Bloomington, USA) catheter.
Guidewire crossing the puncture point and the angioplasty of the ATA and DPA vessels.
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Covidien, Plymouth, USA) balloon angioplasty was performed across the puncture followed by 0.014" 2.5/3.0 mm tapered balloon (EV3, Covidien, Plymouth, USA) to the ATA (Fig. 3). Check angiogram revealed good run off to the DPA and the metatarsal artery and a palpable DPA was present.
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Distal ATA (black arrow) reconstituted by peroneal artery (red arrow). Diseased DPA post pasty (blue arrow).
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Post stenting of DPA across the retrograde puncture point.
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Santa Clara, USA) drug eluting stent was deployed across the distal DPA (covering the puncture point). Subsequent angiogram showed rapid outflow to the digital vessels (Fig. 5).
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(a) Angiogram of left distal PTA. (b) Unsuccessful attempt at passage of wire towards distal PTA. (c) Crossing the PTA beyond the retrograde puncture point. (d) Post angioplasty of PTA.
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However, the guide wire was not able to re-enter the true lumen of the distal PTA, despite using a supporting catheter and a multitude of wires (Fig. 6a and b). There was good flow into the medial plantar artery on completion (Fig. 6c and d).