Author + information
- Daigo Kanamori1
Patient initials or identifier number
Relevant clinical history and physical exam
A 64 year-old woman referred to our hospital because of intractable rest pain of left lower limb, and non-healing ulcer of a left 3rd digit. She had the history of diabetes Mellitus and chronic renal failure on hemodialysis. Five years ago, she had been undergone below knee amputation of her right leg due to foot gangrene.
Relevant test results prior to catheterization
Her ankle-brachial index (ABI) was 0.78 on the left side. Pulsed-wave Doppler recording showed decreased velocity and plateau wave pattern in the left dorsalis pedis artery, indicating severe stenosis or occlusion of the left anterior tibial artery.
Relevant catheterization findings
The initial angiogram revealed the left anterior and posterior tibial artery was totally occluded. Only peroneal artery was run off at below the knee lesion, but tibioperoneal trunk (TPT) was occluded.
Though we attempted revascularization for the TPT lesion, we could not cross the TPT lesion with antegrade or transcollateral approach. Therefore, we moved on to retrograde approach from a peroneal artery. Peroneal artery punctured under fluoroscopic guidance, the TPT lesion successfully crossed with this retrograde approach. After wire crossing, the TPT lesion was dilated with 3 x 40 mm balloon. Balloon tamponade performed at peroneal puncture site with 2.5 x 40 mm balloon, and hemostasis was successfully achieved. After endovascular therapy, the rest pain disappeared within a day and the ulcer of the 3rd digit healed in several weeks. ABI was improved to 0.97.
We successfully re canalized the total occlusion of the tibioperoneal trunk with bidirectional approach via peroneal artery access. Peroneal artery puncture may be safe and effective option for endovascurar therapy in patients with critical limb ischemia.