Teaching Case

Non-healing toe defect in patient with diabetes, treated by repeated PTA and stent implantation.

A patient with diabetes for 15 years, had a 5th toe defect for one month. Distal pressures were not measured as the calcified arteries were not compressible. Angiography (Fig. 1) revealed a tight stenosis of the anterior tibial artery (ATA), occlusion of the posterior tibial artery and occlusion of the proximal part of the peroneal artery (PA). PTA was performed using a 3mm/4cm balloon catheter in the ATA and a 2.5mm/10cm balloon catheter in the PA. Both arteries were reopened (Fig. 2).

Three months later there was ATA restenosis and fibular artery reocclusion. Plain balloon angioplasty of the ATA (Fig. 3) was successful (diameter 3.25mm). Eight months later the patient returned with phlegmon. The ATA was still patent, but because of ATA restenosis (the second restenosis at the same site) we decided to implant an NIR stent 25mm dilated by 3.5mm balloon (Fig. 4). Since this procedure the patient has been symptom-free for nine months and the defect has healed.

PTA of the crural arteries is usually our procedure of first choice, and crural bypass is performed only in patients in whom either PTA has failed or was not feasible. The crural arteries in diabetic patients are usually extensively diseased. Our experience is that sometimes even successful (PTA or surgical) revascularisation does not remove the symptoms while, on the contrary, in some patients even partial (one vessel) revascularisation can help with limb salvage. Our policy is to try to dilate all accessible arteries (i.e. where it is possible to cross the stenosis or occlusion by wire).

Stent implantation can help to maintain the flow to the periphery in those cases where PTA fails because of restenosis, elastic recoil or occlusive dissection. It is known that stented arteries tend to occlude in the long run (but most patients do not have follow-up angiography and we use it only in clinical failures).Another option is to perform a simple Duplex sonography to confirm patency of the intervene vessles.We have experienced that if a reopened artery (with or without a stent) stays open long enough for defect healing to occur, the symptomatic period has been successfully handled.