By Ajay Mhatre MD, and Richard Heuser MD, FACC FSCAI FACP FESC
We present a case of a 78-year-old man with critical limb ischemia of the right foot with a nonhealing ulcer of the right lateral malleolus. We performed diagnostic angiography via the right radial artery. Diagnostic angiography showed an occluded right anterior tibial artery with reconstitution distally, a mildly diseased peroneal artery and a patent posterior tibial artery.
There was moderate to severe complex appearing calcified plaque in the tibial peroneal (TP) trunk. On physical exam, the dorsalis pedis artery could be felt faintly. Angiography of the left foot showed distal anterior tibial artery reconstitution in the foot.
We elected to proceed with intervention of the right TP trunk artery by gaining access via the right posterior tibial artery. This was done due to complex appearing nature of the TP trunk plaque. We felt it may be safer to attempt retrograde crossing first as opposed to antegrade crossing. We thought that there was a risk of possible dissection via the antegrade access route, which would have therefore stopped blood flow to the lower leg.
Editor’s note: See “Retrograde Crossing: When the Front Door Is Locked, Look for Another Way In!” for more details and images from this case.