Avaliação das artérias podais ao eco-Doppler / Assessment of the pedal arteries with Duplex Scanning

Resumo A ultrassonografia vascular com Doppler é um método não invasivo útil no diagnóstico e planejamento terapêutico da doença oclusiva das artérias podais. A artéria pediosa dorsal é a continuação direta da artéria tibial anterior e tem trajeto retilíneo no dorso do pé, dirigindo-se medialmente ao primeiro espaço intermetatarsiano, onde dá origem a seus ramos terminais. A artéria tibial posterior distalmente ao maléolo medial se bifurca e dá origem às artérias plantar lateral e plantar medial. A plantar medial apresenta menor calibre e segue medialmente na planta do pé, enquanto a plantar lateral é mais calibrosa, seguindo um curso lateral na região plantar e formando o arco plantar profundo, o qual se anastomosa com a artéria pediosa dorsal através da artéria plantar profunda. A avaliação das artérias podais pode ser realizada de maneira não invasiva com exame de eco-Doppler, com adequado nível de detalhamento anatômico.

Abstract Vascular Doppler ultrasound is a noninvasive method that can help in diagnostic and therapeutic planning in case of pedal arterial obstructive disease. The dorsalis pedis artery is the direct continuation of the anterior tibial artery and follows a straight course along the dorsum of the foot, leading medially to the first intermetatarsal space, where it gives off its terminal branches. The posterior tibial artery forks distal to the medial malleolus and gives rise to the lateral plantar and medial plantar arteries. The medial plantar artery has a smaller caliber and runs medially in the sole of the foot, while the lateral plantar artery is of larger caliber, following a lateral course in the plantar region and forming the deep plantar arch, which anastomoses with the dorsalis pedis artery via the deep plantar artery. The arteries of the foot can be assessed noninvasively with Doppler, providing an adequate level of anatomical detail.

Evaluación de la permeabilidad posterior a procedimientos endovasculares para pacientes con obstrucciones arteriales en miembros inferiores / Evaluation of permeability following endovascular procedures in patients with lower limb arterial obstructions

Introducción. La enfermedad arterial periférica es una patología de difícil diagnóstico dado que su manifestación, en general, es asintomática, hecho que condiciona el avance significativo en su historia natural y el diagnóstico en estadio avanzado en la mayoría de los casos. Su prevalencia varía entre 3 y 18, mayor que la percibida por los profesionales de la salud, así como sus repercusiones clínicas, sociales y económicas, convirtiéndola en un importante problema de salud. Materiales y métodos. Estudio de cohorte retrospectiva con pacientes llevados a procedimiento endovascular para manejo de obstrucciones arteriales en miembros inferiores entre febrero de 2010 y agosto de 2016, en el que se evaluó la nueva obstrucción arterial en un seguimiento a un año. Se realizó un análisis de supervivencia no paramétrico a través del método de Kaplan-Meier para describir la frecuencia (tasa de incidencia e incidencia acumulada) de nueva obstrucción arterial. Resultados. Ingresaron 102 pacientes de 183 llevados a angioplastia, con edad promedio de 70,7 años (DE: 9,6) y predominio del sexo masculino con 56 pacientes (54,9 %). Durante el primer año de seguimiento, 18 pacientes (17,7 %) presentaron reestenosis (tasa de incidencia de 19,9 eventos por cada 100 pacientes al año). El mayor periodo de reestenosis fueron los primeros 120 días del seguimiento, con posterior estabilidad y presentación de mayor tasa de reestenosis nuevamente en los últimos 120 días del seguimiento, y en pacientes con intervención mixta (supra e infragenicular). Conclusión. La incidencia de reestenosis al año fue del 17,7 %, con permeabilidad superior al 80 %. Los procedimientos endovasculares son una estrategia segura que ofrece resultados similares a los reportados en la literatura

Peripheral arterial disease is a pathology difficult to diagnose, since it mainly remains asymptomatic, which conditions the significant advance in its natural history and why at diagnosis it appears advanced in most patients. The prevalence of the disease has been determined in multiple studies, and varies from 3 to 18, higher than that perceived by health professionals, as well as its repercussions, both clinical, social, and economic. It constitutes a major health problem and remains an underestimated and underdiagnosed disease. Endovascular interventions of peripheral vascular pathologies are considered a fundamental treatment tool. However, there is no complete clarity regarding the patency time after endovascular interventions in the management of arterial occlusion, nor on methods that increase the degree of effectiveness of the procedure

Colgajo Perforante en Propela de la Arteria Tibial Posterior: Reporte de un caso / Posterior Tibial Artery Perforator Propeller Flap. A Case Report

ResumenHistóricamente la reconstrucción de tejidos blandos del tercio distal de la pierna ha constituido un gran desafío quirúrgico para el cirujano plástico, a pesar de los múltiples avances en materia de colgajos pediculados y libres. En la actualidad los colgajos perforantes en propela son una excelente opción reconstructiva muy utilizada para cubrir defectos de tejidos blandos a este nivel con o sin exposición ósea, tendinosa, vascular y/o nerviosa. Esta técnica reconstructiva tiene como ventajas que no requiere anastomosis microquirúrgicas lo cual reduce el tiempo operatorio y que la localización precisa de los vasos perforantes puede realizarse fácilmente con un doppler manual por parte de los cirujanos en sala de operaciones.Se presenta el caso clínico de un paciente masculino de 14 años de edad a quien se le realizó un colgajo perforante en propela de la Arteria Tibial Posterior para cubrir un defecto de tejidos blandos producido por la resección de una contractura cicatrizal a nivel del tercio distal de la pierna derecha y del dorso del pie derecho, que le afectaba funcional y estéticamente. Se pretende dar a conocer el procedimiento y sus resultados, con el fin de difundir otra opción reconstructiva de dicha zona anatómica, que no involucre técnicas microquirúrgicas.

AbstractHistorically soft tissue reconstruction of the distal third of the leg has been a significant surgical challenge for the plastic surgeon despite the many advances in pedicled and free flap subject. Among the various surgical alternatives to rebuild lower limb defects, reverse flow sural flap and the soleus flap may be mentioned and in many cases are viable options, taking into account the area to rebuild and the assessment by the surgeon. Nonetheless, at present, propeller perforator flaps are an excellent reconstructive option widely used in lower limbs to cover soft tissue defects with or without bone, tendon, vascular and/or nervous exposure. These techniques have the main advantage that they do not require performing vascular anastomosis, therefore, knowledge in microsurgery is not indispensable, it requires the precise location of the perforating arteries to use through a manual doppler, this represents less difficulty and operative time when performing the procedureThe authors present a clinical case of a 14-year-old male patient, who underwent a propeller perforator flap from the Posterior Tibial Artery to cover a soft tissue defect produced by the excision of a scar contracture of the third distal of the right leg and dorsal right foot that affected him functionally and esthetically. The authors intend to create awareness of the procedure and its results, in order to disclose another reconstructive option for foot and distal leg that does not involve microsurgical techniques.

Common Peroneal Neuropathy With Anterior Tibial Artery Occlusion: A Case Report

Peroneal neuropathy is a common mononeuropathy of the lower limb. Some studies have reported cases of peroneal neuropathy after vascular surgery or intervention. However, no cases of peroneal neuropathy with occlusion of a single peripheral artery have been previously reported. A 73-year-old man was referred with a 3-week history of left-sided foot drop. He had a history of valvular heart disease and arrhythmia, and had previously been treated with percutaneous coronary intervention. Computed tomography angiogram of the lower extremity showed proximal occlusion of the left anterior tibial artery. An electrodiagnostic study confirmed left common peroneal neuropathy. After diagnosis, anticoagulation therapy was started and he received physical therapy.

Higher division of popliteal artery: a case report.

During the routine dissection of anatomy in an adult male cadaver at the department of anatomy, Manipal University, Manipal, higher division of popliteal artery was observed on the right side. This artery divided proximal to upper border of popliteus muscle into anterior and posterior tibial arteries. Inferomedial genicular artery which is usually a branch of popliteal artery was found to be arising from anterior tibial artery. However arterial branching pattern and point of bifurcation of popliteal artery on the left side were usual. The knowledge of these variations will be useful for angiography or various surgical approaches during knee joint surgery.

Recanalização da artéria tibial anterior via artéria pediosa: relato de caso / Anterior tibial artery recanalization through dorsalis pedis artery: a case report

Os autores relatam um caso de abordagem mista para o tratamento endovascular de doença oclusiva da artéria tibial anterior por acesso pedioso retrógrado, no qual a abordagem tradicional anterógrada foi inadequada em vencer uma oclusão. A técnica parece oferecer uma opção para procedimentos endovasculares, que objetivam o tratamento de lesões da artéria tibial anterior em que a via anterógrada convencional mostre-se inadequada.

The authors report the case of mixed approach for endovascular treatment of occlusive disease of the anterior tibial artery by retrograde pedal artery access where the traditional antegrade approach failed to overcome a segmental occlusion. The technique seems to offer an option for endovascular procedures aimed at treating occlusion of the anterior tibial artery in cases where the conventional antegrade approach demonstrates to be inappropriate.

Mycotic aneurysm of the tibioperoneal trunk: a first manifestation of an infected endocarditis / Aneurisma micótico de tronco tíbio-fibular: a primeira manifestação de uma endocardite infecciosa

Infrapopliteal mycotic aneurysm resulting from endocarditis is rare, with only a few reported cases. We describe the case of a 28-year-old male patient who was suffering with pain and edema in the right leg. The ultrasound revealed an aneurysm of the right tibioperoneal trunk and a deep vein thrombosis (DVT). The patient was admitted and developed acute congestive heart failure, being diagnosed with possible endocarditis. A pseudo-aneurysm was revealed by arteriography. Aggressive antibiotic treatment was initiated, and open surgery confirmed a mycotic pseudo-aneurysm of the tibioperoneal trunk. To our knowledge, this is the 8th case reported of an infected aneurysm in this particular location.

Aneurisma micótico infra-poplíteo resultante de endocardite infecciosa é raro, com apenas alguns casos relatados. Descrevemos o caso de um paciente de 28 anos do sexo masculino que apresentou dor e edema na perna direita. A ultrassonografia demonstrou um aneurisma do tronco tíbio-fibular e trombose venosa profunda do membro inferior direito. O paciente foi internado e desenvolveu falência cardíaca aguda, sendo diagnosticado de endocardite bacteriana. Um pseudo-aneurisma foi evidenciado na arteriografia. Antibioticoterapia agressiva foi iniciada e cirurgia aberta confirmou um pseudo-aneurisma micótico do tronco tibio-fibular. Para o nosso conhecimento, este é o oitavo caso relatado de aneurisma infectado localizado especificamente nesta região.

Anterior Tibial Artery Angioplasty and Stenting by Retrograde Pedal Artery Approach in Diabetic Patient with Critical Limb Ischemia: A Case Report / 대한혈관외과학회지

Endovascular therapy of critical limb ischemia is indicated in high risk patients, especially the diabetics. The ipsilateral antegrade femoral approach is the most common access site. When this approach fails, the retrograde pedal artery percutaneous approach can be considered. A 51-year-old diabetic male patient was presented with severe rest pain and gangrene on his right 4th toe. Computed tomography angiography showed multilevel calcific arterial occlusive disease, involving the popliteal and proximal anterior tibial arteries. Below knee angioplasty and stenting of the right leg was done through ipsilateral antegrade femoral approach and retrograde pedal artery approach. The C-arm guided retrograde pedal approach for calcific artery was useful for recanalization of the occluded anterior tibial artery when antegrade approach failed.

Clinical Outcomes of Infrapopliteal Angioplasty in Patients With Critical Limb Ischemia

BACKGROUND AND OBJECTIVES: With recent advances in equipment and techniques, infrapopliteal angioplasty has shown results that are comparable to those of surgical bypass in patients with critical limb ischemia (CLI). In this study, we evaluated the efficacy and the feasibility of infrapopliteal angioplasty in patients with CLI. SUBJECTS AND METHODS: Between March 2002 and May 2008, infrapopliteal angioplasty was performed on 118 limbs of 101 patients (79 males; mean age 66 years) with CLI (Rutherford category 4, 5 or 6). Freedom from reintervention, limb salvage, and overall survival were analyzed. RESULTS: The median follow-up duration was 30 months. Initial technical and clinical success rates were 69.5% and 83.1%, respectively. No major complication requiring surgical intervention developed after angioplasty. Among 82 limbs with initial technical success, the rate of freedom from any reintervention at 2 years was 70.7% and that from limb salvage was 97.6%. Young age and Rutherford category 6 at initial presentation were independent predictors associated with poor 2 year primary patency in these patients with CLI. Overall survival at 1 year was 86.4% and that at 2 years 76.3%. A history of cerebrovascular accident was an independent predictor associated with poor 2 year survival in these patients. CONCLUSION: Infrapopliteal angioplasty as a primary choice of treatment in CLI patients showed favorable clinical outcomes and feasibility.

Anterolateral crural island flaps:anatomical study and clinical applications for tibial skin defect / 中华骨科杂志

Objective To explore surgical methods of repairing tibial skin defect using the anterolateral crural island flap.Methods The location,external diameters,anastomosis and distribution of perforators from the anterior tibial artery and the peroneal artery in the anterior septum were observed in 40 cadaveric specimens.Arterial angiography was performed in 4 fresh legs.Clinically,11 cases with tibial skin defect were repaired with the anterolateral crural island flap.There were 7 males and 4 females,with an average of 36 years (20-59 years).The area of the skin defect ranged from 6 cm×4 cm to 12 cm×4 cm.Results An arterial chain was formed by the interconnection of the superficial peroneal artery,the anterior septocutaneous perforator from distal part of the anterior tibial artery and the anterior end-perforator of the peroneal artery.It ran in the anterior septum and went along with the superficial peroneal nerve to supply blood to adjacent fascia and skin.The external diameters of the three perforators were (1.4±0.4) mm,(1.0±0.4) mm and (1.5±0.4) mm respectively,and the external diameter of the arterial chain was (0.6±0.2) mm.Clinically,we designed 4 methods to repair 11 cases of tibial skin defect successfully with the anterolateral cnnal island flap.The anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 2 cases;ascending branch of the anterior septocutaneous perforator from distal part of the anterior tibial artery was used as pedicle in 3 cases;descending branch of the anterior septocutaneous perforator from distalpart of the anterior tibial artery was used as pedicle in 3 cases;ascending branch of the anterior end-perforator of the peroneal artery was used as pedicle in 3 cases.The area of the flaps ranged between 7 cm×5 cm and 13 cm×5 cm.All patients were followed up with a mean time of 1.5 years.All flaps survived totally without diabrosis and swelling.Conclusion The anterolateral island flaps pedicled with perforators arising from the anterior septum of the lower leg is a good choice for surgeons to repair tibial skin defect.

Preliminary study on elasticity of medium-sized artery in patients with type 2 diabetes through strain-blood pressure index / 中华超声影像学杂志

Objective To investigate the clinical value and the feasibility of strain-blood pressure index(SBPI) in assessing the elasticity of brachial artery and anterior tibial artery in patients with type 2 diabetes mellitus. Methods Forty-six type 2 diabetic patients and 50 healthy volunteers were involved. Maxmum of circumferential strain (CSmax) of brachial artery and anterior tibial artery were acquired through strain and strain rate imaging(Xstrain). Local systolic blood pressure(LSBP) and local diastolic blood pressure(LDBP) of brachial artery and anterior tibial artery were measured at the same time. SBPI,tibial-brachial index (TBI), and ankle-brachial index(ABI) were calculated, SBPI = CSmax/[(LSBP-LDBP) /LDBP]×100%,TBI = SBPI of anterior tibial artery/SBPI of brachial artery, ABI = LSBP of anterior tibial artery/LSBP of brachial artery. Parameters were compared between the case group and the control group. Results SBPI of anterior tibial artery and TBI had significant difference between the case group and the control group( P < 0.05), while SBPI of brachial and ABI had no significant difference( P >0. 05).Conclusions SBPI might be a new index for evaluating the elasticity of medium-sized arteries in patients with type 2 diabetes, and different changes caused by type 2 diabetes between brachial artery and anterior tibial artery could be reflected by TBI.