Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI and Timothy Kieborz, DO

A 62 year-old white female has had chronic venous stasis ulcers for at least the last 12 to 15 years. For the past 2 years, she has had a non-healing ulcer. She was first seen at the end of January at the wound care center. At that time, she states that she had undergone a cardiovascular work-up, including an arterial work-up, and was told everything was normal. She even underwent a cardiac catheterization that was completely normal.

Her risk factors for coronary disease include a remote smoking history and a family history of heart disease. She also has degenerative joint disease. Treatment for her non-healing ulcer which measured 4.1 cm x 2.5 x 0.3 was unsuccessful and the physicians at the wound care center felt that the arterial insufficiency had not been significantly evaluated. We saw her in consultation. Physical examination revealed her blood pressure to be 134/75, her pulse was 70 and regular, her weight was 135 lbs, and height was 5 feet 4 inches, with O2 saturations of 100%. The patient’s cardiac examination was unremarkable. Her abdomen was benign, and she had good femoral pulses and good dorsalis pedal pulses bilaterally.

The ulcer was as described. Her ankle brachial indexes were 1.12 on the right, 0.92 on the left. In spite of the non-invasive test being negative, she underwent an arteriogram and long leg run-off. The abdominal aorta, iliac and femoral arteries were completely normal bilaterally. The popliteal artery was normal bilaterally, with 3-vessel run-off on the left side; however, the mid-portion of the right posterior tibial artery was 100% occluded.[1] Figure 2 shows that the pedal flow was minimal and there were no significant pedal collaterals present.

We selectively engaged the contralateral iliac artery to go down the right superficial femoral artery (SFA). The Quick-Cross catheter (Spectranetics, Inc., Colorado Springs, Colorado) was used and a 0.035 hydrophilic wire was passed across the total occlusion. We confirmed the distal position in the pedal vessel (Figure below) with an arteriogram. We then exchanged for a 0.014 Cougar wire (Medtronic, Inc., Minneapolis, Minnesota) and performed laser atherectomy with a 0.9 laser.

Following this, we performed balloon angioplasty using the Invatec 2.5, 120 cm balloon (Bethlehem, Pennsylvania). At the end of the procedure, excellent filling was noted to the dorsum of the foot, and the posterior tibial artery was now fully functional with TIMI-3 flow.

This is a case of successful laser recanalization of a 100% occluded posterior tibial artery.