Retrograde crossing through the pedal arch for totally occluded tibial artery

Area of Science:

• Vascular surgery
• Interventional cardiology
• Peripheral artery disease research

Background:

• Critical limb ischemia (CLI) is a severe manifestation of peripheral artery disease (PAD), primarily caused by atherosclerosis.
• Atherosclerotic occlusion of the crural arteries, particularly the dorsalis pedis and posterior tibial arteries, presents a complex therapeutic challenge.
• The pedal arch is crucial for collateral circulation in the lower limb.

Observation:

• A rare case of critical limb ischemia with exclusive occlusion of the anterior tibial artery and dorsalis pedis artery, alongside the paramalleolar posterior tibial artery, was observed.
• The patient presented with severe symptoms necessitating advanced revascularization strategies.
• Standard antegrade approaches were initially considered but posed significant challenges due to the specific occlusion pattern.

Findings:

• Successful antegrade recanalization of the occluded anterior tibial and dorsalis pedis arteries was achieved.
• A novel retrograde recanalization of the posterior tibial artery through the pedal arch was successfully performed.
• Complete infrapopliteal revascularization was accomplished, restoring blood flow to the affected limb.

Implications:

• This case demonstrates the feasibility and effectiveness of a combined antegrade and retrograde approach for complex infrapopliteal arterial occlusions.
• The retrograde pedal arch crossing technique offers a valuable alternative for treating rare atherosclerotic patterns in CLI.
• Successful revascularization led to significant wound healing and limb salvage, highlighting the importance of tailored endovascular strategies.