Arterial Interventions and Peripheral Arterial Disease (PAD)
Matthew Hoyer, MD (he/him/his)
The Johns Hopkins Hospital
Disclosure(s): No financial relationships to disclose
Mark L. Lessne, MD
Vascular and Interventional Radiologist
Vascular & Interventional Specialists, Charlotte Radiology
To describe clinical indications for and outcomes of below-the-ankle (BTA) arterial revascularization
To illustrate case-based techniques for BTA arterial revascularizations
To discuss post-procedure end points, management, and follow up after BTA interventions
Peripheral artery disease comprises a range of diseases with the most severe presentation being clinical limb ischemia (CLI). Those with CLI suffer one-year rates of amputation or mortality exceeding 50%, with the global incidence of major amputations between 120-500 million per year. Arterial revascularization has been shown to improve limb salvage rates. While below-the-knee (BTK) techniques have been increasingly used by the interventional community, complete revascularization of the foot may be limited by more distal “below-the-ankle” (BTA) disease, requiring more complex BTA and pedal revascularization strategies. These techniques require special consideration of particular tools and familiarity with anatomy of the foot. The purpose of this exhibit is to review the anatomy, indications, techniques, and outcomes of BTA arterial revascularization.
Clinical Findings/Procedure Details:
In this review, we will detail the relevant anatomy and work up of the patient presenting for potential BTA intervention. An emphasis on pedal anatomy and procedural planning, including the WI-FI classification system, will be reviewed. Various techniques of BTA revascularization will be illustrated through case-based examples, focusing on endovascular tool selection, access techniques, pedal loop reconstruction, anatomic and physiologic endpoints, and alternative treatment options such as deep venous arterialization. Post-procedure monitoring with perfusion and hemodynamic diagnostics and clinical outcomes will be discussed.
Conclusion and/or Teaching Points:
Despite advancements in BTK interventions, BTA disease continues to pose a significant barrier to revascularization of the distal lower extremity. Various BTA revascularization techniques are safe and effective at improving perfusion and wound healing compared to BTK intervention alone. As interventional radiologists’ role in treating critical limb ischemia increases, so must their expertise in treating BTA disease to ensure optimal limb salvage outcomes.