5: TIBIOPERONEAL OCCLUSIVE DISEASE Jean Starr View Full Chapter Figures Only Tables Only Videos Only Print Share Email Send Email Your Name (required) ! Example: John Doe Email Address (required) ! Please enter a valid sender email address. Example: firstname.lastname@example.org CC Me Recipient Email Address (required) ! Separate multiple email address with semi-colons (up to 5). Subject Subject for your email. Message (Maximum characters: 1,000) Please enter your name Please enter your email address Please enter a valid recipient email address. Example:email@example.com Thank you! Your email has been sent to: The recipient(s) will receive an email message that includes a link to the selected article. Recipients may need to check their spam filters or confirm that the address is safe. Return to: Send Another Email An error has occurred sending your email(s). Please try again later or contact an administrator at OnlineCustomer_Service@mheducation.com. Return to: Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Starr J. Starr J Starr, Jean.TIBIOPERONEAL OCCLUSIVE DISEASE. In: Dean SM, Satiani B, Abraham WT. Dean S.M., Satiani B, Abraham W.T. Eds. Steven M. Dean, et al.eds. Color Atlas and Synopsis of Vascular Diseases New York, NY: McGraw-Hill; 2014. http://accesssurgery.mhmedical.com/content.aspx?bookid=1201§ionid=71012795. Accessed April 20, 2018. MLA Citation Starr J. Starr J Starr, Jean.. "TIBIOPERONEAL OCCLUSIVE DISEASE." Color Atlas and Synopsis of Vascular Diseases Dean SM, Satiani B, Abraham WT. Dean S.M., Satiani B, Abraham W.T. Eds. Steven M. Dean, et al. New York, NY: McGraw-Hill, 2014, http://accesssurgery.mhmedical.com/content.aspx?bookid=1201§ionid=71012795. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager Mendeley © Copyright Tools Search Book Top Return Clip Autosuggest Results + PATIENT STORY Print Section ++ ++ An 80-year-old man presented with a nonhealing foot ulcer over the base of the left first metatarsal head (Figure 5-1). It had been present for several months and appeared after he wore a new pair of shoes. He had a history of diabetes and hypertension. There was no previous history of claudication. ++ FIGURE 5-1 Diabetic foot ulcer (arrow), noted to be over a bony prominence with callused edges and unhealthy-appearing base. Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ Lower extremity arterial Doppler studies were completed and showed bilateral ankle-brachial indices (ABIs) greater than 1.2 with triphasic femoral and popliteal waveforms and monophasic tibial waveforms (Figure 5-2). ++ FIGURE 5-2 Left lower extremity noninvasive arterial waveform study showing normal femoral and popliteal pressures and diminished pedal waveforms. Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ Surgical intervention and endovascular procedures were discussed with him. An angiogram was performed that showed no significant occlusive disease above the knee and severe tibial occlusive disease below the knee (Figure 5-3). ++ FIGURE 5-3 Initial angiogram with blue arrows highlighting peroneal disease and red arrows indicating anterior tibial artery disease. Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ Balloon angioplasty was performed on the anterior tibial and peroneal arteries (Figure 5-4), and there was resultant improvement in angiographic results (Figure 5-5). ++ FIGURE 5-4 Balloon angioplasty procedure with the blue arrow indicating the peroneal and red arrow representing the anterior tibial artery balloon. Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ FIGURE 5-5 Final angioplasty demonstrates improved results with the blue arrow pointing to the peroneal and red arrow to the anterior tibial artery. Graphic Jump LocationView Full Size|Favorite Figure|Download Slide (.ppt) ++ Ulcer healing was complete approximately 1 month after the procedure. + EPIDEMIOLOGY Print Section ++ ++ Lower extremity peripheral arterial disease (PAD) affects 8 to 10 million Americans and the incidence increases as the population ages, affecting 12% to 15% of people over the age of 65 years.1 PAD is a main cause of lower extremity amputation, other cardiovascular morbidity, decreased quality of life, and cost to our health care system. Occlusive disease isolated to the tibial or peroneal arterial bed typically occurs in patients with diabetes. Ulceration and gangrene in this patient population is often multifactorial and difficult to treat. Factors contributing to poor healing wounds include tissue ischemia, renal failure, soft tissue or underlying bone infection, excessive pressure, poor glucose control, and inappropriate or inadequate wound care. Prevention of tissue loss is a prime objective in these patients. + ETIOLOGY OR PATHOPHYSIOLOGY Print Section ++ ++ A study of lower extremity amputation segments showed that atherosclerosis and vessel wall medial calcification was prominent in diabetic patients.2 There was also an increased occurrence of severe atherosclerosis in older patients and those with hypertension. Medial calcification was also significant in younger patients less than 70 years of age. Arteriography in diabetic patients with chronic limb ischemia found that 74% had disease below the knee and 66% of these were occlusions.3 Diabetics were found to have more diffuse atherosclerotic disease with greater severity in the tibial vessels and higher occurrence of long-segment occlusions. Calcification within the vessel wall tends to increase in the more distal tibial distribution of the arterial tree. This was not found to be related to any clinical factors.4 + CLINICAL FEATURES Print Section ++ ++ Tibial occlusive disease may often be asymptomatic until tissue loss occurs. Claudication is not a common manifestation unless there coexists more proximal occlusive disease as well. Neuropathy may be a prominent symptom in these patients, especially when diabetes is present. Tissue breakdown often occurs at pressure points over bony prominences and with ill-fitting footwear. + DIFFERENTIAL DIAGNOSIS Print Section ++ ++ The etiology of pedal ulcerations can be multifactorial, and in addition to atherosclerotic occlusive disease, other contributors are poorly controlled diabetes, renal failure, neuropathy, inappropriate pressure, infection, and trauma. + DIAGNOSTIC STUDIES Print Section ++ ++ Noninvasive imaging studies are the best tests to start with to gauge the degree of arterial insufficiency and to try to localize disease location. This may include ABIs, waveform analysis at multiple levels, and color duplex ultrasonography (DUS) of arterial segments. The ABI may be falsely elevated in patients with diabetes due to medial calcinosis causing stiff, incompressible vessel walls. This makes waveform analysis invaluable for determining degree of ischemia. In addition, digit pressures and plethysmographic waveforms are valuable in these patients. DUS has been found to be very good compared to digital subtraction angiography, but not as accurate in delineating the more distal tibial vessels.5 It can, however, be an initial good, noninvasive test to use for therapeutic planning purposes. More in-depth anatomic information can be gleaned with contrast computed tomography angiography (CTA) and magnetic resonance angiography (MRA) studies.6 Advantages are the lack of invasiveness, but the disadvantages include contrast administration and exposure to radiation, as well as the inability to treat the disease within the same setting. MRA has limited application in patients with renal failure due to the possibility of nephrogenic systemic fibrosis. CTA may falsely interpret the anatomy of calcified lesions. Catheter-based angiography with concomitant endovascular intervention offers the most expedient approach to improving flow to an ischemic limb.6 It may also provide better imaging quality and spatial resolution, especially in the face of extensive calcification. Acute thrombus may also be better identified. + MANAGEMENT OR INTERVENTION OPTIONS Print Section ++ ++ Various endovascular options exist, including balloon angioplasty, cryoplasty, stenting, and atherectomy. No single approach truly surpasses the others in terms of results, but these minimally invasive approaches have challenged traditional open surgical revascularization procedures. Surgical options included distal bypass with prosthetic or autogenous graft, endarterectomy with patch angioplasty, and primary amputation. The BASIL trial showed that outcomes were generally similar for patients with critical limb ischemia who were candidates for both surgery and an endovascular approach.7 Surgery was found to be more expensive over the first-year follow-up period. This study, however, was not stratified to examine patients with femoral- popliteal versus tibial occlusive disease. + COMPLICATIONS OR OUTCOMES Print Section ++ ++ Surgical complications include infection, early and late graft occlusion, and medical problems, especially those cardiac in nature. Endovascular complications can include short- and long-term recurrence or occlusion, access site problems, and medical issues. Endovascular tibial interventions have been found to have acceptable limb salvage and wound healing rates, but have a higher rate of reintervention.8 Patients with renal failure, poor pedal flow, and isolated peroneal runoff had worse outcomes. Patients expected to live less than 2 years may be better served with angioplasty first as they may not reap the long-term patency benefit from surgical revascularization.9 Patients who have a reasonable 2-year life expectancy are appropriate surgical candidates, and those with autogenous vein are better treated first with open bypass. + PATIENT EDUCATION AND FOLLOW-UP Print Section ++ ++ Patients should have regular follow-up after endovascular or surgical revascularization to assess patency and success of the procedure. They should be advised about the warning signs of recurrent disease, for which they should notify their physician. Wounds should also be closely followed until completely healed. Patients should be advised about risk factor modification, including smoking cessation, blood pressure control, lipid management, glucose control, weight loss, and appropriate foot care. Avoidance of future tissue loss is the main target of future medical management of these patients. + REFERENCES Print Section ++ +1. +Hirsch AT, Hartman L, Town RJ, Virnig BA. National health care costs of peripheral arterial disease in the Medicare population. Vasc Med. Aug 2008;13(3):209–215. +2. +Soor GS, Vukin I, Leong SW, Oreopoulos G, Butany J. Peripheral vascular disease: who gets it and why? A histomorphological analysis of 261 arterial segments from 58 cases. Pathology. Jun 2008;40(4):385–391. +3. +Graziani L, Silvestro A, Bertone V et al.. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Vasc Endovasc Surg. Apr 2007;33(4):453–460. +4. +Bishop PD, Feiten LE, Ouriel K et al.. Arterial calcification increases in distal arteries in patients with peripheral arterial disease. Ann Vasc Surg. Nov 2008;22(6):799–805. +5. +Eiberg JP, Gr⊘nvall Rasmussen JB, Hansen MA, Schroeder TV. Duplex ultrasound scanning of peripheral arterial disease of the lower limb. Eur J Vasc Endovasc Surg. Oct 2010;40(4):507–512. +6. +Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg. Sep 2010;52(suppl 3): S81–S91. +7. +Adam DJ, Beard JD, Cleveland T et al.. BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre randomised controlled trial. Lancet. Dec 3 2005;366(9501):1925–1934. +8. +Fernandez N, McEnaney R, Marone LK et al.. Predictors of failure and success of tibial interventions for critical limb ischemia. J Vasc Surg. Oct 2010;52(4):834–842. +9. +Bradbury AW, Adam DJ, Bell J et al.. Multicentre randomised controlled trial of the clinical and cost-effectiveness of a bypass-surgery-first versus a balloon-angioplasty-first revascularisation strategy for severe limb ischaemia due to infrainguinal disease. The Bypass versus Angio-plasty in Severe Ischaemia of the Leg (BASIL) trial. Health Technol Assess. Mar 2010;14(14):1–210, iii–iv.