Vascular Imaging of the Foot: The First Step toward Endovascular Recanalization

Abstract

In the past 5 years, with the introduction of new techniques and dedicated materials, endovascular recanalization of distal tibial and pedal vessels has become a valid alternative to inframalleolar bypass for limb salvage in patients with severe arterial occlusive disease, particularly diabetics. Revascularization of the foot is now often performed by using percutaneous transluminal angioplasty; over a 4-year period, the authors performed more than 2500 antegrade interventional procedures in patients with critical limb ischemia, diabetes, and infrainguinal arterial disease. Intraprocedural angiography of the foot is crucial for successful planning and guidance of percutaneous transluminal angioplasty in tibial and pedal arteries, and its effective use requires both anatomic knowledge and technical skill. To select the best revascularization strategy and obtain optimal clinical results, interventional radiologists, cardiologists, and vascular surgeons performing below-the-knee endovascular procedures also must be familiar with the functional aspects of circulation in the foot. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.316115511/-/DC1.

The clinical utility of below‐the‐ankle angioplasty using “transmetatarsal artery access” in complex cases of CLI

“…In 38 (4.68%) patients (28 men; mean age 73.2 ± 11.4 years) who had failed antegrade recanalization and were unavailable for percutaneous retrograde access at the pedal or plantar arteries, required metatarsal artery access to recanalize the target vessels, identified by wound‐related artery and angiosome concepts to restore direct blood flow line to the compromised tissue. All patients signed the informed consent before the procedure and the retrospective study was conducted in accordance with the local ethics committee rules.…”

Clinical outcome of angiosome-oriented infrapopliteal percutaneous transluminal angioplasty for isolated infrapopliteal lesions in patients with critical limb ischemia

“…According to this concept, the foot can be divided into five perfusion territories (angiosomes) supplied by three arteries (the ATA, PTA, and PA) that originate from the main popliteal artery and adjacent angiosomes connected by collateral vessels (6,19). This strategy is particularly import- diabetic critical limb ischemia, because it allows for the specific selection of the target artery that directly supplies blood flow to the wound.…”

Patency of runoff detected by MR angiography at 3.0 T with cuff-compression: a predictor of successful endovascular recanalization below the knee

“…In our study, the procedure was unsuccessful in 11 limbs without complete anastomosis between the anterior and posterior pedal circulatory pathways; therefore, ER remains a challenge in these patients. Sometimes, when occlusion of the pedal-plantar loop occurs because of severe arteriosclerosis or forefoot amputation, the deep pedal arch often becomes the dominant pedal-plantar connection and provides supplementary access [10,20].…”