Teaching Case

Diabetic arteriopathy with multisegmental stenoses of all lower limb arteries

The diabetic patient was suffering from a right-sided superinfected non-healing pedal ulcer presenting Stage IV disease (Fontaine) of peripheral arterial disease. Proximal arteries down to the popliteal artery were without stenosis but showing medial calcifications typical for diabetic arteriopathy. The posterior tibial artery was occluded, the interosseal artery was stenosed at the middle level of the lower limb which was dielated by use of a 3 mm balloon. Main finding was a long-segment irregular stenosis of the dorsal pedal artery at the level of the ankle (Fig. 1)

In order to dilate the stenoses of the dorsal pedal artery, an 0.018 stiff guide wire with a floppy platinum tip (Platinum Plus, BSIC) was managed into the dorsal pedal artery. A 2mm balloon catheter on a 3.7 F shaft was inserted over the guidewire into the stenotic segment and serial dilation over 30 s each was performed (Fig. 2 a,b). After dilation the control angiogram shows a smoother lumen (Fig. 3 a) and the pedal arch is restored. Before the stenosis was passed, the patient underwent oral and intraarterial vasodilating medication. After the intervention an iv. infusion of prostacycline was administered for 4 hours. Pedal and lower limb PTA is only indicated if a severe stage (IV Fontaine) is present and no surgical options are given. These limitations are relevant because of the potential risks of PTA with occlusion of the small arteries and subsequent limb loss.