Dorsal-Plantar Loop Technique Using Chronic Total Occlusion Devices via Anterior Tibial Artery
A 61-year-old male was admitted to our hospital due to a nonhealing diabetic ulcer management and transferred from orthopedics. He had a history of hypertension, diabetes, and 40 pack years smoking, and had received percutaneous transluminal angioplasty with stent implantation at right superficial femoral artery. He presented with extensive ulceration localized at dorsum, sole and toes of the left foot, persistent rest pain, and a Rutherford classification of grade 5. On physical examination, we could feel the arterial pulse at the femoral and popliteal levels, but the pulse of left dorsalis pedis artery was not palpable. Before angiography, we checked computed tomography of the lower-extremities, but the result was confusing because of severe calcification.\nThe left common femoral artery was punctured, and a 5 Fr Ansel sheath (Cook, Bloomington, IN, USA) was moved into the left popliteal artery and then diagnostic angiography was performed. Baseline angiography showed total occlusion of the left infrapopliteal artery with proximal portion of three distal run-off vessels (). The first target vessel for recanalization was posterior tibial artery (PTA) because of the site of the ulcer. However, we could not see the ostium of PTA, and wiring through PTA and anterior tibial artery (ATA) was difficult. Therefore, wiring through the peroneal artery was done, and balloon angioplasty was then conducted at the left peroneal artery. After peroneal artery balloon angioplasty, we could see distal flow of PTA, however, an attempt to move the wire to the ostium of PTA was unsuccessful. Since diffuse wound was distributed on the entire area of the foot and we could not find the puncture site (), transpedal retrograde approach could not also be performed. Therefore, we tried to pass the wire through the ATA, but wiring through ATA failed. We decided to pass the wire using subintimal approach method. The wire through the true lumen of ATA was confirmed by the use of contrast injection, and then balloon angioplasty was performed using 3.0×100 mm EverCross balloon (ev3 Inc., Plymouth, MN, USA). Next, we tried to pass the wire through the ostium of PTA again, but failed. Finally, dorsal-plantar loop technique via the anterior tibial artery with CTO devices was performed as an alternative method. A 300-cm-long 014-inch hydrophilic guidewire (PT2; Boston Scientific, Natick, MA, USA) using the Corsair microcatheter (Asahi Intecc Co. Ltd., Aichi, Japan) could be advanced antegradely from distal ATA via dorsal-plantar loop (consisting of dorsalis pedis artery, deep plantar artery, deep plantar arch and lateral plantar artery) to proximal PTA. When balloon angioplasty was tried with 2.0×120 mm NanoCross balloon (ev3 Inc., Plymouth, MN, USA), the balloon could not penetrate toward proximal PTA because of resistance. Therefore, we extracted the wire, which was retrogradely passed from ATA via the left femoral sheath by using snare catheter (pfm medical ag, Koln, Germany). After successful wire passage, balloon angioplasty was performed with 3.0×100 mm EverCross balloon, penetrating from proximal to distal part of PTA (). Final angiography demonstrated a well visualized anterior tibial artery, dorsal-plantar loop, and posterior tibial artery with improved flow (). After 24 hour of observation, the patient was transferred to an orthopedics without complications, and then wound healing was achieved by surgical repair by necrotic tissue debridement and skin graft.