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Relevant clinical history and physical exam
An 82 year-old male patient visited our hospital due to ongoing right foot pain. Large ulcers of Rutherford VI were observed on the dorsum and malleolus of his right foot with greenish discharge at the ulcer site. He was on medication for diabetes and hypertension with history of an ex-smoker (1 pack/day for 50 years). Both dorsalis pulses were nearly undetected. The sizes of ulcer were 4 cm x 3.5 cm at right dorsum and 3 cm x 3 cm at right lateral malleolus.
Relevant test results prior to catheterization
The ABI on right foot was 0.62 before the procedure. The Lower extremity CT angiography performed showing approximately 95% luminal narrowing at proximal portion of anterior tibial artery (ATA) with diffuse severe stenosis of overall tibial artery (PTA) with calcification.
Relevant catheterization findings
Peripheral angiography was performed by antegrade approach at right femoral artery with 6 french terumo sheath. The lesion of ATA focalized at the proximal portion; however, the lesion of PTA was diffuse and totally occluded at the mid to distal portion of the artery with abundant microcollteral vessels.
We first tried to across the lesion with Fielder XT (Asahi) wire but the lesion was too hard to penetrate. Gaia (Asahi) first along with micro catheter (Rubicon 14, Boston) were used as next choice; however, we failed to cross the lesions. The alternative strategy which we chose was retrograde approach by using micro puncture wire. After the distal segment of PTA was successfully punctured, Fielder XT (Asahi) wire was selected for an access into the micro catheter which was used during the antegrade approach. As the next step, we used snare to pull out the retrograde wire through the femoral sheath. After the wire was pulled out, we exchanged the wire into Hi-Torque Command (Abbott, 300 cm). Balloon dilatation was performed sufficiently from the proximal PTA (Sterling, Boston, 3.0 mm X 150 mm) to lateral plantal artery (Coyote, Boston, 2.5 mm X 150 mm). Final peripheral angiography demonstrated the recovery of right proximal to distal PTA and plantar brach flows. The follow up ABI of right foot was 0.81. Two week later, the ulcers were nearly restored, in which we could underwent skin graft over ulcers.
Direct revascularization of the ischemic angiosome is necessary for complicated ulcer healing. However, we anticipated the healing of ulcers by treating the most critical stenoses although the ATA and peroneal artery were the main supplying arteries of the occurred ulcers. Indirect revascularization may be the effective alternative procedural strategy when direct revascularization run in to a brick wall.