Chapter 5

### PATIENT STORY

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.

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.

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.

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.

###### FIGURE 5-5

Final angioplasty demonstrates improved results with the blue arrow pointing to the peroneal and red arrow to the anterior tibial artery.

Ulcer healing was complete approximately 1 month after the procedure.

### EPIDEMIOLOGY

• 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

• A ...

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