Skip to main content
SpringerLink
Log in

Interventional Treatment of the Below-the-Ankle Peripheral Artery Disease

  • Living reference work entry
  • First Online:
PanVascular Medicine

Abstract

In the following chapter, the below-the-ankle vascular anatomy, vessel disease distribution, and treatment strategies for percutaneous revascularization will be described in detail. Description of anatomical variants that are important for revascularization treatment of ischemic patients will be provided. Vessel disease distribution according to different comorbidities in a large series of treated patients will be reported. Current concept in endovascular treatment of patients with critical limb ischemia, such as the “angiosome concept” and the concept of “wound related artery,” will be explained. Standard and extreme revascularization technique will be described to provide the reader with a complete overview of the below-the-ankle peripheral artery disease.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

Similar content being viewed by others

Abbreviations

ATA:

Anterior tibial artery

BTA:

Below-the-ankle

BTK:

Below-the-knee

CLI:

Critical limb ischemia

DPA:

Dorsalis pedis artery

LPA:

Lateral plantar artery

MPA:

Medial plantar artery

PA:

Peroneal artery

PTA:

Posterior tibial artery

SFA:

Superficial femoral artery

References

  • Abdelhamid MF, Davies RS, Rai S, Hopkins JD, Duddy MJ, Vohra RK (2010) Below-the-ankle angioplasty is a feasible and effective intervention for critical leg ischaemia. Eur J Vasc Endovasc Surg 39:762–768

    Article  PubMed  CAS  Google Scholar 

  • Alexandrescu V (2009) Below-the-ankle subintimal angioplasty: how far can we push this application for lower limb preservation in diabetic patients? J Endovasc Ther 16:617–618

    Article  PubMed  Google Scholar 

  • Alexandrescu V, Hubermont G (2012a) The challenging topic of diabetic foot revascularization: does the angiosome-guided angioplasty may improve outcome. J Cardiovasc Surgy 53:3–12

    CAS  Google Scholar 

  • Alexandrescu V, Söderström M, Venermo M (2012b) Angiosome theory: fact or fiction? Scand J Surg 101:125–131

    Article  CAS  Google Scholar 

  • Alexandrescu VA, Hubermont G, Philips Y, Guillaumie B, Ngongang C, Vandenbossche P, Azdad K, Ledent G, Horion J (2008) Selective primary angioplasty following an angiosome model of reperfusion in the treatment of Wagner 1–4 diabetic foot lesions: practice in a multidisciplinary diabetic limb service. J Endovasc Ther 15:580–593

    Article  PubMed  Google Scholar 

  • Alexandrescu V, Vincent G, Azdad K, Hubermont G, Ledent G, Ngongang C, Filimon AM (2011) A reliable approach to diabetic neuroischemic foot wounds: below-the-knee angiosome-oriented angioplasty. J Endovasc Ther 18:376–387

    Article  PubMed  Google Scholar 

  • Alson MD, Lang EV, Kaufman JA (1997) Pedal arterial imaging. J Vasc Interv Radiol 8:9–18

    Article  PubMed  CAS  Google Scholar 

  • Attinger CE, Evans KK, Bulan E, Blume P, Cooper P (2006) Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg 117:261S–293S

    Article  PubMed  CAS  Google Scholar 

  • Azuma N, Uchida H, Kokubo T, Koya A, Akasaka N, Sasajima T (2012) Factors influencing wound healing of critical ischaemic foot after bypass surgery: Is the angiosome important in selecting bypass target artery? Eur J Vasc Endovasc Surg 43:322–328

    Article  PubMed  CAS  Google Scholar 

  • Biondi-Zoccai G, Sangiorgi G (2009) Below-the-knee/ankle revascularization: tools of the trade. J Endovasc Ther 16:613–616

    Article  PubMed  Google Scholar 

  • Biondi-Zoccai G, Sangiorgi G (2010) What goes around comes around: the role of the subintimal foot loop technique for limb salvage. J Endovasc Ther 17:722–724

    Article  PubMed  Google Scholar 

  • Darcy MD (1991) Lower-extremity arteriography: current approach and techniques. Radiology 178(3):615–621

    Article  PubMed  CAS  Google Scholar 

  • Faglia E, Clerici G, Clerissi J, Mantero M, Caminiti M, Quarantiello A (2007) When is a technically successful peripheral angioplasty effective in preventing above-the-ankle amputation in diabetic patients with critical limb ischaemia? Diabet Med 24:823–829

    Article  PubMed  CAS  Google Scholar 

  • Ferraresi R, Palena LM, Mauri G, Manzi M (2013) Tips and tricks for a correct “endo approach”. J Cardiovasc Surg (Torino) 54(6):685–711

    CAS  Google Scholar 

  • Fusaro M, Dalla Paola L, Biondi-Zoccai G (2007a) Pedal-plantar LOOP technique for a challenging below-the-knee chronic total occlusion: a novel approach to percutaneous revascularization in critical lower limb ischemia. J Invasive Cardiol 19:34–37

    Google Scholar 

  • Fusaro M, Dalla Paola L, Brigato C, Marangotto M, Nicolini S, Rripay R, Biondi-Zoccai GG (2007b) Plantar to dorsalis pedis artery subintimal angioplasty in a patient with critical foot ischemia: a novel technique in the armamentarium of the peripheral interventionist. J Cardiovasc Med (Hagerstown) 8(11):977–980

    Article  Google Scholar 

  • Gandini R, Pipitone V, Stefanini M et al (2007) The “Safari” technique to perform difficult subintimal infragenicular vessels. Cardiovasc Intervent Radiol 30:469–473

    Article  PubMed  Google Scholar 

  • Graziani L, Silvestro A, Monge L, Boffano GM, Kokaly F, Casadidio I et al (2008) Transluminal angioplasty of peroneal artery branches in diabetics: initial technical experience. Cardiovasc Intervent Radiol 31:49–55

    Article  PubMed  Google Scholar 

  • Hinchliffe RJ, Andros G, Apelqvist J, Bakker K, Friederichs S, Lammer J, Lepantalo M, Mills JL, Reekers J, Shearman CP, Valk G, Zierler RE, Schaper NC (2012) A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res 28(Suppl 1):179–217

    Article  Google Scholar 

  • Iida O, Nanto S, Uematsu M, Ikeoka K, Okamoto S, Dohi T, Fujita M, Terashi H, Nagata S (2010) Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia. Catheter Cardiovasc Interv 75:830–836

    PubMed  Google Scholar 

  • Iida O, Soga Y, Hirano K, Kawasaki D, Suzuki K, Miyashita Y, Terashi H, Uematsu M (2012) Long term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the knee lesions. J Vasc Surg 55:363–370

    Article  PubMed  Google Scholar 

  • Karnabatidis D, Katsanos K, Spiliopoulos S et al (2009) Incidence, anatomical location, and clinical significance of compressions and fractures in infrapopliteal balloon-expandable metal stents. J Endovasc Ther 16:15–22

    Article  PubMed  Google Scholar 

  • Katsanos K, Karnabatidis D, Siablis D (2011) Commentary: below-the-ankle angioplasty: to stent or not to stent. J Endovasc Ther 18(1):43–45

    Article  PubMed  Google Scholar 

  • Katsanos K, Diamantopoulos A, Spiliopoulos S, Karnabatidis D, Siablis D (2013) Below-the-ankle angioplasty and stenting for limb salvage: anatomical considerations and long-term outcomes. Cardiovasc Intervent Radiol 36:926–935

    Article  PubMed  Google Scholar 

  • Kawarada O, Yokoi Y (2008) Dorsalis pedis artery stenting for limb salvage. Catheter Cardiovasc Interv 71:976–982

    Article  PubMed  Google Scholar 

  • Kawarada O, Yokoi Y, Higashimori A, Waratani N, Waseda K, Honda Y, Fitzgerald PJ (2011) Stent-assisted below-the-ankle angioplasty for limb salvage. J Endovasc Ther 18(1):32–42

    Article  PubMed  Google Scholar 

  • Manzi M, Palena LM (2013) Retrograde percutaneous transmetatarsal artery access: new approach for extreme revascularization in challenging cases of critical limb ischemia. Cardiovasc Intervent Radiol 36(2):554–557

    Article  PubMed  Google Scholar 

  • Manzi M, Fusaro M, Ceccacci T, Erente G, Dalla Paola L, Brocco E (2009a) Clinical results of below-the-knee intervention using pedal-plantar loop technique for the revascularization of foot arteries. J Cardiovasc Surg 50:331–337

    CAS  Google Scholar 

  • Manzi M, Fusaro M, Ceccacci T, Erente G, Dalla Paola L, Brocco E (2009b) Clinical results of below-the knee intervention using pedal-plantar loop technique for the revascularization of foot arteries. J Cardiovasc Surg (Torino) 50(3):331–337

    CAS  Google Scholar 

  • Manzi M, Cester G, Palena LM, Alek J, Candeo A, Ferraresi R (2011) Vascular Imaging od the foot: the first step toward endovascular recanalization. Radiographics 31:1623–1636

    Article  PubMed  Google Scholar 

  • Manzi M, Palena LM, Brocco E (2012) Is digital arteries recanalization useful to preserve the foot functionality and avoid toes amputation, after pedal recanalization? Clinical results. J Cardiovasc Surg (Torino) 53(1):61–68

    CAS  Google Scholar 

  • Neville RF, Attinger CE, Bulan EJ, Ducic I, Thomassen M, Sidawy AN (2009) Revascularization of a specific angiosome for limb salvage: does the target artery matter? Ann Vasc Surg 23:367–373

    Article  PubMed  Google Scholar 

  • Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, on behalf of the TASC II Working Group (2007) Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 45:S5–S67

    Article  PubMed  Google Scholar 

  • Palena LM, Manzi M (2012) Extreme below-the-knee interventions: retrograde transmetatarsal or transplantar arch access for foot salvage in challenging cases of critical limb ischemia. J Endovasc Ther 19(6):805–811

    Article  PubMed  Google Scholar 

  • Palena LM, Brocco E, Manzi M (2013) The clinical utility of below-the-ankle angioplasty using “transmetatarsal artery access” in complex cases of CLI. Catheter Cardiovasc Interv. doi:10.1002/ccd.24992 (Epub ahead of print)

    PubMed  Google Scholar 

  • Peregrin JH, Koznar B, Kovác J, Lastovicková J, Novotný J, Vedlich D, Skibová J (2010) PTA of infrapopliteal arteries: long-term clinical follow-up and analysis of factors influencing clinical outcome. Cardiovasc Intervent Radiol 33:720–725

    Article  PubMed  Google Scholar 

  • Spinosa DJ, Leung DA, Hathun NL et al (2003) Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion. J Vasc Interv Radiol 14:1449–1454

    Article  PubMed  Google Scholar 

  • Spinosa DJ, Harthun NL, Bissonette EA, Cage D, Leung DA, Angle JF et al (2005) Subintimal arterial flossing with antegrade–retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interv Radiol 16:37–44

    Article  PubMed  Google Scholar 

  • Standring S (2008) Gray’s anatomy, 40th edn. Elsevier, Philadelphia, PA, USA, pp 19103--2879

    Google Scholar 

  • Taylor GI, Pan WR (1998) Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 102:599–616

    Article  PubMed  CAS  Google Scholar 

  • Varela C, Acín F, de Haro J, Bleda S, Esparza L, March JR (2010) The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model. Vasc Endovasc Surg 44:654–660

    Article  Google Scholar 

  • Yamada T, Gloviczki P, Bower TC, Naessens JM, Carmichael SW (1993) Variations of the arterial anatomy of the foot. Am J Surg 166(2):130–135

    Article  PubMed  CAS  Google Scholar 

  • Zhu YQ, Zhao JG, Liu F, Wang JB, Cheng YS, Li MH, Wang J, Li J (2009) Subintimal angioplasty for below-the-ankle arterial occlusions in diabetic patients with chronic critical limb ischemia. J Endovasc Ther 16:604–606

    Article  PubMed  Google Scholar 

  • Zhu YQ, Zhao JG, Li MH, Liu F, Wang JB, Cheng YS, Wang J, Li J (2010) Retrograde transdorsal-to-plantar or transplantar-to-dorsal intraluminal re-entry following unsuccessful subintimal angioplasty for below-the-ankle arterial occlusion. J Endovasc Ther 17(6):712–721

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Interventional Peripheral CathLab Unit, Humanitas Gavazzeni, Bergamo, Italy

    Roberto Ferraresi

  2. Interventional Radiology Unit, Policlinico Abano Terme, Italy

    Luis Mariano Palena & Marco Manzi

  3. Radiology Unit, IRCCS Policlinico San Donato, Milan, Italy

    Giovanni Mauri

Authors
  1. Roberto Ferraresi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Luis Mariano Palena
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Giovanni Mauri
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Marco Manzi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roberto Ferraresi .

Editor information

Editors and Affiliations

  1. Akademisches Lehrkrankenhaus MLU, Bitterfeld-Wolfen, Germany

    Peter Lanzer

Rights and permissions

Reprints and permissions

Copyright information

© 2014 Springer-Verlag Berlin Heidelberg

About this entry

Cite this entry

Ferraresi, R., Palena, L.M., Mauri, G., Manzi, M. (2014). Interventional Treatment of the Below-the-Ankle Peripheral Artery Disease. In: Lanzer, P. (eds) PanVascular Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-37393-0_135-1

Download citation

  • DOI: https://doi.org/10.1007/978-3-642-37393-0_135-1

  • Received:

  • Accepted:

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Online ISBN: 978-3-642-37393-0

  • eBook Packages: Springer Reference MedicineReference Module Medicine

Publish with us

Policies and ethics

Search

Navigation