Recanalization of anterior tibial artery in a single-vessel patency situation

Clinical History

Long segment stenosis and partial occlusion of anterior tibial artery as the only remaining artery for the right foot

Imaging Findings

Patient presented with stage IV disease with a nonhealing ulcer of her right forefoot. She was suffering from diabetes for many years but smoking was denied. Intraarterial angiography did not reveal any stenoses of the femoral and politeal arteries but showed severe disease of the lower leg arteries with occlusion of the interosseal and posterior tibial artery.The sole remaining artery was the anterior tibial artery that showed a tight stenosis proximally and a complete occlusion of the middle segment with a very small distal but patent segment (Fig. 1 a and b).

Discussion

After antegrade puncture of the ipsilateral common femoral artery and by use of a 4 F hydrophilically coated catheter and a 0.035 hydrophilic guidewire of 260 cm length and a curved tip, the tibial artery was passed until the end of the guidewire reached the distal segment of the anterior tibial artery at the level of the ankle. A 120 cm long 5 F balloon catheter with a 3 mm balloon of 4 cm length was advanced into the anterior tibial artery and all stenotic and occluded segments were subsequently dilated (Fig. 2 a). Periprocedural medication included 5000 IU of heparin intraarterially. Control angiography showed restored patency of the artery with no dissection (Fig. 2 b and c).A pedal pulse was palpable after the intervention. The ulcer healed within 3 weeks. Indication for interventional treatment was justified by the clinical situation. Since intervention of a single vessel outflow is risky, it should be restricted to stage IV and sometimes stage III disease. It is recommended only if there is a distal segment of the artery patent to allow outflow into the pedal vasculature. In most cases use of 0.035 in guidewires and 5 F balloons are possible. They have the advantage of sufficient vis-a-tergo to be guided even over tight stenoses. If these devices are to large to be easily advanced into the lower limb arteries, alternatively smaller balloons of 2.8 F guided over 0.018 guidewires may be used.

Differential Diagnosis List

Final Diagnosis

Percutaneous recanalization of anterior tibial artery

URL:	https://www.eurorad.org/case/621
DOI:	10.1594/EURORAD/CASE.621
ISSN:	1563-4086