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Infrainguinal Arteries: Revascularization
Keith B. Quencer, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Peripheral artery disease (PAD)
              • Occlusion or stenosis of noncoronary, noncerebral arteries
                • Symptoms range from asymptomatic to rest pain/tissue loss
              • PAD risk factors
                • Age > 50 years, obesity, male sex, hypertension, hyperlipidemia
                • Diabetes
                  • Have more aggressive PAD
                  • 5x higher amputation rate
                  • Typically affects distal, small-caliber vessels
              • Severity of symptoms depends on degree of stenosis, collateral circulation, intensity of exertion
            • Ankle-brachial index (ABI)
              • Noninvasive evaluation of peripheral circulation
              • Performed with blood pressure (BP) cuff and continuous Doppler
              • Ankle:brachial systolic pressure ratio
                • Use higher ankle pressure [dorsalis pedis (DP) or posterior tibial (PT)]
                • Divide by higher of 2 brachial artery pressures
              • Interpretation
                • ≥ 1.3: Calcified vessels
                  • Medial calcification can be seen in end-stage renal disease or diabetes
                  • Unreliable examination as calcification prevents vessel compression
                  • Use toe-brachial index instead
                • 0.9-1.3: Normal
                • < 0.9: Abnormal; indicates presence of PAD
                  • 0.4-0.9: Mild to moderate PAD; intermittent claudication likely
                  • < 0.4: Severe PAD; critical limb ischemia likely
            • Toe-brachial index (TBI)
              • > 0.7: Normal
              • 0.5-0.7: Mild
              • 0.35-0.5: Moderate
              • < 0.35
                • Moderate to severe if toe pressure > 30 mm Hg
                • Severe if toe pressure < 30 mm Hg
            • Intermittent claudication (IC)
              • Reproducible crampy muscular leg pain with exercise, relieved with rest
                • Pain pattern suggests lesion location
                  • Buttock pain: Aorta/common iliac artery
                  • Thigh pain: External iliac femoral artery/common femoral artery (CFA)
                  • Calf pain: Superficial femoral artery (SFA)/popliteal artery
                  • Foot pain: Tibial/peroneal artery
              • Typical ABI between 0.4-0.9
            • Chronic limb ischemia (CLI)
              • Rest pain or tissue loss/nonhealing wounds
                • Peripheral neuropathy may initially present similarly
                  • With CLI, pain worsens when leg elevated, relieved when leg dependent
              • Severe arterial obstruction or occlusion
              • Often multifocal disease
              • Typical ABI < 0.4
            • Acute limb ischemia (ALI)
              • Sudden interruption of arterial blood flow to extremity
              • Usually due to embolus or in situ thrombosis
                • Embolic source may be cardiac or aneurysm
              • Symptoms: 6 Ps of ALI
                • Pain, pulselessness, pallor, paresthesias, paralysis, and poikilothermia (i.e., cold)
              • Rutherford classification for ALI
                • I: Viable
                  • No sensory loss; no motor loss
                  • May have audible Doppler arterial pulse
                • IIa: Marginally threatened
                  • Pain/sensory loss, no weakness
                • IIb: Immediately threatened
                  • Pain/sensory loss and mild weakness
                • III: Irreversible (nonviable)
                  • Anesthesia/paralysis, muscle rigor
          • Physical Examination in Peripheral Artery Disease

            • Diminished/absent pulses distal to stenosis
              • Infrainguinal lesion: Normal femoral, decreased or absent DP/PT pulses
            • Bruit over stenosis
            • Cool extremity, distal hair loss
            • Poor wound healing
              • Inspect area between toes as kissing toe ulcers from pressure between metatarsal heads often seen
            • Dependent rubor and elevation pallor
              • Often seen in CLI
          • Fontaine Stages of PAD

            • Stage 1: Asymptomatic but decreased pulses; ABI < 0.9
              • Up to 75% of patients with PAD are asymptomatic
                • Could be related to sedentary/limited lifestyle
            • Stage 2: IC
              • 2a: Distance > 200 m
              • 2b: Distance < 200 m
            • Stage 3: Ischemic rest pain
            • Stage 4: Ulceration, gangrene
          • Trans-Atlantic Inter-Society Consensus II (TASC II): Categorization of Atherosclerotic Lesions Based on Morphology

            • Type A
              • Single stenosis ≤ 10 cm in length
              • Single occlusion ≤ 5 cm in length
              • Endovascular therapy is treatment of choice
            • Type B
              • Multiple lesions ≤ 5 cm in length
              • Single stenosis or occlusion ≤ 15 cm in length
              • Heavily calcified lesion ≤ 5 cm in length
              • Typically, endovascular treatment preferred
            • Type C
              • Multiple lesions adding up to > 15 cm
              • Recurrent stenosis after 2 endovascular treatments
              • Multiple lesions > 3 cm but < 5 cm in length
              • Surgery preferred; consider endovascular therapy if high-risk patient for open revascularization
            • Type D
              • Chronic total occlusions (CTO) > 20 cm or involving popliteal artery/proximal trifurcation
              • Poor endovascular results, surgery is standard
          • Infrainguinal Vascular Anatomy

            • CFA
              • Continuation of external iliac artery below inguinal ligament
                • Overlies femoral head
                • Angiographic surrogate of inguinal ligament are inferior epigastric/deep circumflex iliac artery origins
              • Surgical endarterectomy treatment of choice for atherosclerotic disease of CFA
              • Bifurcates into superficial and deep femoral arteries
            • SFA
              • From CFA bifurcation to caudal end of adductor (Hunter) canal
                • Distal portion of SFA, within adductor canal, is prone to atherosclerotic disease
                  • 3/4 of femoropopliteal occlusions occur within adductor canal
                • Relatively absent of side branch vessels
            • Profunda femoris artery
              • a.k.a. deep femoral artery
              • Extends from femoral bifurcation into thigh musculature
              • Provides important collaterals in setting of SFA stenosis/occlusion
              • Perforating branches resistant to atherosclerosis
            • Popliteal artery
              • SFA becomes popliteal artery at adductor hiatus
              • Courses behind knee, between gastrocnemius heads
              • Bifurcates into anterior tibial, tibioperoneal trunk
            • Anterior tibial artery (ATA)
              • Passes anteriorly through intraosseous membrane
              • Becomes DP artery at ankle level
            • Tibioperoneal trunk
              • a.k.a. tibial fibular trunk
              • Variable but typically short segment
              • Divides into peroneal and PT arteries
              • Peroneal artery
                • a.k.a. fibular artery
                • Relatively resistant to atherosclerosis
                • Normally patent to just above ankle joint
                • Has communicating branches with ATA
              • PT artery
                • Supplies posterior compartment
                  • Distally forms plantar arch of foot

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Procedure Steps

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Things to Do

                          OUTCOMES

                          • Complications

                            • Expected Outcomes

                              Selected References

                              1. Solimeno G et al: Technical perspectives in the management of complex infrainguinal arterial chronic total occlusions. J Vasc Surg. 75(2):732-9, 2022
                              2. Anand GM et al: Single versus multiple vessel endovascular tibial artery revascularization for critical limb ischemia: a review of the literature. Int J Angiol. 29(3):175-9, 2020
                              3. Bevan GH et al: Evidence-based medical management of peripheral artery disease. Arterioscler Thromb Vasc Biol. 40(3):541-53, 2020
                              4. Kim SM et al: Device selection in femoral-popliteal arterial interventions. Interv Cardiol Clin. 9(2):197-206, 2020
                              5. Kim TI et al: New innovations and devices in the management of chronic limb-threatening ischemia. J Endovasc Ther. 27(4):524-39, 2020
                              6. Levin SR et al: Lower extremity critical limb ischemia: a review of clinical features and management. Trends Cardiovasc Med. 30(3):125-30, 2020
                              7. Ansel GM: Drug-coated balloons versus drug-eluting stents in the femoropopliteal artery: comparing apples to oranges? J Cardiovasc Surg (Torino). 60(4):456-9, 2019
                              8. Naghi J et al: New developments in the clinical use of drug-coated balloon catheters in peripheral arterial disease. Med Devices (Auckl). 9:161-74, 2016
                              9. Pernès JM et al: Infrapopliteal arterial recanalization: a true advance for limb salvage in diabetics. Diagn Interv Imaging. 96(5):423-34, 2015
                              10. Thukkani AK et al: Endovascular intervention for peripheral artery disease. Circ Res. 116(9):1599-613, 2015
                              11. Hardman RL et al: Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 31(4):378-88, 2014
                              12. Sarode K et al: Drug delivering technology for endovascular management of infrainguinal peripheral artery disease. JACC Cardiovasc Interv. 7(8):827-39, 2014
                              13. Creager MA et al: Clinical practice. Acute limb ischemia. N Engl J Med. 366(23):2198-206, 2012
                              14. Hynes BG et al: Endovascular management of acute limb ischemia. Ann Vasc Surg. 26(1):110-24, 2012
                              15. Van Den Berg J et al: Lesion characteristics of patients with chronic critical limb ischemia that determine choice of treatment modality. J Cardiovasc Surg (Torino). 53(1):45-52, 2012
                              16. Karnabatidis D et al: Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia. Cardiovasc Intervent Radiol. 34(6):1123-36, 2011
                              17. Lawrence PF et al: When should open surgery be the initial option for critical limb ischaemia? Eur J Vasc Endovasc Surg. 39 Suppl 1:S32-7, 2010
                              18. Norgren L et al: Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 45 Suppl S:S5-67, 2007
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    • Outcomes

                                      TERMINOLOGY

                                      • Definitions

                                        • Peripheral artery disease (PAD)
                                          • Occlusion or stenosis of noncoronary, noncerebral arteries
                                            • Symptoms range from asymptomatic to rest pain/tissue loss
                                          • PAD risk factors
                                            • Age > 50 years, obesity, male sex, hypertension, hyperlipidemia
                                            • Diabetes
                                              • Have more aggressive PAD
                                              • 5x higher amputation rate
                                              • Typically affects distal, small-caliber vessels
                                          • Severity of symptoms depends on degree of stenosis, collateral circulation, intensity of exertion
                                        • Ankle-brachial index (ABI)
                                          • Noninvasive evaluation of peripheral circulation
                                          • Performed with blood pressure (BP) cuff and continuous Doppler
                                          • Ankle:brachial systolic pressure ratio
                                            • Use higher ankle pressure [dorsalis pedis (DP) or posterior tibial (PT)]
                                            • Divide by higher of 2 brachial artery pressures
                                          • Interpretation
                                            • ≥ 1.3: Calcified vessels
                                              • Medial calcification can be seen in end-stage renal disease or diabetes
                                              • Unreliable examination as calcification prevents vessel compression
                                              • Use toe-brachial index instead
                                            • 0.9-1.3: Normal
                                            • < 0.9: Abnormal; indicates presence of PAD
                                              • 0.4-0.9: Mild to moderate PAD; intermittent claudication likely
                                              • < 0.4: Severe PAD; critical limb ischemia likely
                                        • Toe-brachial index (TBI)
                                          • > 0.7: Normal
                                          • 0.5-0.7: Mild
                                          • 0.35-0.5: Moderate
                                          • < 0.35
                                            • Moderate to severe if toe pressure > 30 mm Hg
                                            • Severe if toe pressure < 30 mm Hg
                                        • Intermittent claudication (IC)
                                          • Reproducible crampy muscular leg pain with exercise, relieved with rest
                                            • Pain pattern suggests lesion location
                                              • Buttock pain: Aorta/common iliac artery
                                              • Thigh pain: External iliac femoral artery/common femoral artery (CFA)
                                              • Calf pain: Superficial femoral artery (SFA)/popliteal artery
                                              • Foot pain: Tibial/peroneal artery
                                          • Typical ABI between 0.4-0.9
                                        • Chronic limb ischemia (CLI)
                                          • Rest pain or tissue loss/nonhealing wounds
                                            • Peripheral neuropathy may initially present similarly
                                              • With CLI, pain worsens when leg elevated, relieved when leg dependent
                                          • Severe arterial obstruction or occlusion
                                          • Often multifocal disease
                                          • Typical ABI < 0.4
                                        • Acute limb ischemia (ALI)
                                          • Sudden interruption of arterial blood flow to extremity
                                          • Usually due to embolus or in situ thrombosis
                                            • Embolic source may be cardiac or aneurysm
                                          • Symptoms: 6 Ps of ALI
                                            • Pain, pulselessness, pallor, paresthesias, paralysis, and poikilothermia (i.e., cold)
                                          • Rutherford classification for ALI
                                            • I: Viable
                                              • No sensory loss; no motor loss
                                              • May have audible Doppler arterial pulse
                                            • IIa: Marginally threatened
                                              • Pain/sensory loss, no weakness
                                            • IIb: Immediately threatened
                                              • Pain/sensory loss and mild weakness
                                            • III: Irreversible (nonviable)
                                              • Anesthesia/paralysis, muscle rigor
                                      • Physical Examination in Peripheral Artery Disease

                                        • Diminished/absent pulses distal to stenosis
                                          • Infrainguinal lesion: Normal femoral, decreased or absent DP/PT pulses
                                        • Bruit over stenosis
                                        • Cool extremity, distal hair loss
                                        • Poor wound healing
                                          • Inspect area between toes as kissing toe ulcers from pressure between metatarsal heads often seen
                                        • Dependent rubor and elevation pallor
                                          • Often seen in CLI
                                      • Fontaine Stages of PAD

                                        • Stage 1: Asymptomatic but decreased pulses; ABI < 0.9
                                          • Up to 75% of patients with PAD are asymptomatic
                                            • Could be related to sedentary/limited lifestyle
                                        • Stage 2: IC
                                          • 2a: Distance > 200 m
                                          • 2b: Distance < 200 m
                                        • Stage 3: Ischemic rest pain
                                        • Stage 4: Ulceration, gangrene
                                      • Trans-Atlantic Inter-Society Consensus II (TASC II): Categorization of Atherosclerotic Lesions Based on Morphology

                                        • Type A
                                          • Single stenosis ≤ 10 cm in length
                                          • Single occlusion ≤ 5 cm in length
                                          • Endovascular therapy is treatment of choice
                                        • Type B
                                          • Multiple lesions ≤ 5 cm in length
                                          • Single stenosis or occlusion ≤ 15 cm in length
                                          • Heavily calcified lesion ≤ 5 cm in length
                                          • Typically, endovascular treatment preferred
                                        • Type C
                                          • Multiple lesions adding up to > 15 cm
                                          • Recurrent stenosis after 2 endovascular treatments
                                          • Multiple lesions > 3 cm but < 5 cm in length
                                          • Surgery preferred; consider endovascular therapy if high-risk patient for open revascularization
                                        • Type D
                                          • Chronic total occlusions (CTO) > 20 cm or involving popliteal artery/proximal trifurcation
                                          • Poor endovascular results, surgery is standard
                                      • Infrainguinal Vascular Anatomy

                                        • CFA
                                          • Continuation of external iliac artery below inguinal ligament
                                            • Overlies femoral head
                                            • Angiographic surrogate of inguinal ligament are inferior epigastric/deep circumflex iliac artery origins
                                          • Surgical endarterectomy treatment of choice for atherosclerotic disease of CFA
                                          • Bifurcates into superficial and deep femoral arteries
                                        • SFA
                                          • From CFA bifurcation to caudal end of adductor (Hunter) canal
                                            • Distal portion of SFA, within adductor canal, is prone to atherosclerotic disease
                                              • 3/4 of femoropopliteal occlusions occur within adductor canal
                                            • Relatively absent of side branch vessels
                                        • Profunda femoris artery
                                          • a.k.a. deep femoral artery
                                          • Extends from femoral bifurcation into thigh musculature
                                          • Provides important collaterals in setting of SFA stenosis/occlusion
                                          • Perforating branches resistant to atherosclerosis
                                        • Popliteal artery
                                          • SFA becomes popliteal artery at adductor hiatus
                                          • Courses behind knee, between gastrocnemius heads
                                          • Bifurcates into anterior tibial, tibioperoneal trunk
                                        • Anterior tibial artery (ATA)
                                          • Passes anteriorly through intraosseous membrane
                                          • Becomes DP artery at ankle level
                                        • Tibioperoneal trunk
                                          • a.k.a. tibial fibular trunk
                                          • Variable but typically short segment
                                          • Divides into peroneal and PT arteries
                                          • Peroneal artery
                                            • a.k.a. fibular artery
                                            • Relatively resistant to atherosclerosis
                                            • Normally patent to just above ankle joint
                                            • Has communicating branches with ATA
                                          • PT artery
                                            • Supplies posterior compartment
                                              • Distally forms plantar arch of foot

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Preprocedure Imaging

                                            • Getting Started

                                              PROCEDURE

                                              • Patient Position/Location

                                                • Procedure Steps

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Things to Do

                                                      OUTCOMES

                                                      • Complications

                                                        • Expected Outcomes

                                                          Selected References

                                                          1. Solimeno G et al: Technical perspectives in the management of complex infrainguinal arterial chronic total occlusions. J Vasc Surg. 75(2):732-9, 2022
                                                          2. Anand GM et al: Single versus multiple vessel endovascular tibial artery revascularization for critical limb ischemia: a review of the literature. Int J Angiol. 29(3):175-9, 2020
                                                          3. Bevan GH et al: Evidence-based medical management of peripheral artery disease. Arterioscler Thromb Vasc Biol. 40(3):541-53, 2020
                                                          4. Kim SM et al: Device selection in femoral-popliteal arterial interventions. Interv Cardiol Clin. 9(2):197-206, 2020
                                                          5. Kim TI et al: New innovations and devices in the management of chronic limb-threatening ischemia. J Endovasc Ther. 27(4):524-39, 2020
                                                          6. Levin SR et al: Lower extremity critical limb ischemia: a review of clinical features and management. Trends Cardiovasc Med. 30(3):125-30, 2020
                                                          7. Ansel GM: Drug-coated balloons versus drug-eluting stents in the femoropopliteal artery: comparing apples to oranges? J Cardiovasc Surg (Torino). 60(4):456-9, 2019
                                                          8. Naghi J et al: New developments in the clinical use of drug-coated balloon catheters in peripheral arterial disease. Med Devices (Auckl). 9:161-74, 2016
                                                          9. Pernès JM et al: Infrapopliteal arterial recanalization: a true advance for limb salvage in diabetics. Diagn Interv Imaging. 96(5):423-34, 2015
                                                          10. Thukkani AK et al: Endovascular intervention for peripheral artery disease. Circ Res. 116(9):1599-613, 2015
                                                          11. Hardman RL et al: Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 31(4):378-88, 2014
                                                          12. Sarode K et al: Drug delivering technology for endovascular management of infrainguinal peripheral artery disease. JACC Cardiovasc Interv. 7(8):827-39, 2014
                                                          13. Creager MA et al: Clinical practice. Acute limb ischemia. N Engl J Med. 366(23):2198-206, 2012
                                                          14. Hynes BG et al: Endovascular management of acute limb ischemia. Ann Vasc Surg. 26(1):110-24, 2012
                                                          15. Van Den Berg J et al: Lesion characteristics of patients with chronic critical limb ischemia that determine choice of treatment modality. J Cardiovasc Surg (Torino). 53(1):45-52, 2012
                                                          16. Karnabatidis D et al: Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia. Cardiovasc Intervent Radiol. 34(6):1123-36, 2011
                                                          17. Lawrence PF et al: When should open surgery be the initial option for critical limb ischaemia? Eur J Vasc Endovasc Surg. 39 Suppl 1:S32-7, 2010
                                                          18. Norgren L et al: Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 45 Suppl S:S5-67, 2007