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Background: Etiology of osteochondral lesions of the talus (OLT) is multifactorial and may develop from trauma, genetics, or hypovascularity. The talar dome is supplied by the posterior tibial artery (PTA) and, to a lesser degree, the sinus tarsi artery (STA). The role of talar dome hypovascularity on OLT remains poorly studied. We aimed to determine any relationship between the diameter of PTA (dPTA) and STA (dSTA) and the incidence and characteristics of talus OLT., Methods: This retrospective study included 77 patients with OLT and 77 subjects as a matched control group (age range: 30-40 years). Using magnetic resonance imaging, the dPTA was measured 1 cm above the tibial plafond, at the plafond, and at the level of medial malleolar tip. Likewise, dSTA was measured at the level of the talar neck. The area, volume, depth, localization, and surgical intervention for OLT were recorded as well., Results: The study group had significantly smaller dPTA at all 3 levels (1.05 ± 0.22 mm, 0.99 ± 0.18 mm, 0.98 ± 0.31 mm, proximal to distal, respectively) compared with controls (1.25 ± 0.23 mm, 1.20 ± 0.22 mm, 1.14 ± 0.18 mm, respectively) ( P  < .001). The dSTA was also significantly smaller in the study group compared with the control group (0.5 ± 0.11 mm vs 0.57 ± 0.08 mm, respectively; P  = .001). The mean dPTA (of all 3 levels) cutoff value for predicting the occurrence of OLT was 1.1 mm with 74% sensitivity and 75% specificity. A significant inverse correlation was observed between OLT area and arterial diameters ( P  < .001)., Conclusion: Smaller luminal dPTA and dSTA appear to be associated with higher incidence of OLT, with defect size inversely correlated to arterial diameter., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Background: There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using supra-inguinal inflow for revascularization of infra-inguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infra-femoral targets., Methods: The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB from the aortoiliac arteries to the popliteal and tibial arteries. Patients were stratified into 3 cohorts based on outflow targets (above-knee [AK] popliteal, below-knee [BK] popliteal, and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival (AFS), and major adverse limb events (MALEs) were compared. A Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes., Results: Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, while the remaining used the aorta or common iliac artery as inflow. In terms of the distal target, the AK popliteal was used in 116 (28.8%), the BK popliteal in 151 (27.5%), and tibial vessels in 136 (43.7%) cases. BK popliteal and tibial bypasses, compared to AK popliteal bypasses, were more commonly performed in patients with chronic limb-threatening ischemia (69.5% and 69.9% vs. 48.3%; P < 0.001). Vein conduit was more often used for tibial bypass than for AK and BK popliteal bypasses (46.3% vs. 21.9% and 16.3%; P < 0.001). In the perioperative period, BK popliteal and tibial bypass patients had higher reoperation rates (16.9% and 13.2% vs. 5.2%; P = 0.02) and lower primary patency (89.4% and 89% vs. 95.7%; P = 0.04) than AK bypass patients. At 1 year, compared with AK popliteal bypasses, BK and tibial bypasses demonstrated lower primary patency (81.9% vs. 56.7% vs. 52.4%, P < 0.001) and freedom from MALE (77.6% vs. 70.2% vs. 63.1%, P = 0.04), although AFS was not significantly different (89.7% vs. 90.6% vs. 83.8%, P = 0.19).On multivariable analysis, compared with AK popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio 1.9, 95% confidence interval, 1.03-3.51, P = 0.04). Subanalysis of patients with chronic limb-threatening ischemia demonstrated significantly higher primary patency in the AK popliteal cohort at discharge and 1 year, but no difference in AFS or freedom from MALE between the cohorts at follow-up., Conclusions: LEB with supra-inguinal inflow appear to have acceptable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency but not with MALE or AFS., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Retrograde tibio-pedal access represents a feasible method for endovascular revascularization when antegrade methods fail. The article offers an extensive review of retrograde tibio-pedal access, emphasizing the technique and documented outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI., Methods: A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300 mm (1 point), and poor pedal runoff score (1 point). Patients were then divided into 3 groups: low risk (0 or 1 points), moderate risk (2 points), and high risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis [>70%], or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-oriented outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention: new bypass graft, jump/interposition graft revision) were evaluated., Results: 1,607 patients (55% male, average age 60 years, 3,846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic origin. Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day major amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate risk and high risk exceeded the goal threshold. For the OPG, freedom from MALE was 60 ± 5%, 46 ± 5%, and 22 ± 9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.008). Overall AFS was 55 ± 5%, 37 ± 6%, and 18 ± 7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.003)., Conclusions: Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short- and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To examine first attempt success and overall success of real-time ultrasound guided peripheral arterial cannulation in infants., Study Design: Retrospective review of 477 ultrasound guided peripheral arterial cannulations in infants less than 1 year of age. Procedural and patient characteristics were evaluated to better understand factors related to procedural success., Results: Ultrasound guided peripheral arterial cannulation had a first attempt success rate of 65% and an overall success rate of 86%. Success rates significantly differed by arterial location ( p  < 0.001). First attempt success and overall success were highest in the radial artery (72%, 91%) and lowest in the posterior tibial artery (44%, 71%). Success was more likely with greater age and greater weight ( p  = 0.006, p  = 0.002)., Conclusion: Success rates are high when using a real-time ultrasound-guided technique for peripheral arterial cannulation in infants. An infant's weight and selected artery are strong predictors of success when performing peripheral arterial cannulation. The use of procedural ultrasound may reduce unnecessary attempts and minimize procedure-related harm., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Structural changes in the lower limb's arterial wall in amateur endurance runners are a rare incidental finding, represented just by several case reports., Aim: Study the incidence of non-atherosclerotic lower limb artery wall changes in defined group of amateur endurance runners and identify relationship with the training parameters and the relevant biochemical markers., Methods: Amateur male athletes engaged in endurance running for more than 5 years were enrolled. Tibial and anterior popliteal arteries on each side were examined by ultrasound with focus on non-atherosclerotic structural wall changes: intima-medial border blurring, presence and character of non-atherosclerotic noduli. Subsequently the descriptive and correlation analysis were performed., Results: The study enrolled 20 amateur male endurance runners from Black Swan Triathlon Club Slovakia. The low atherosclerotic risk was represented by normal lipid levels, BMI under 30 kg/m 2 and non-smokers in all participants. At least one type of structural artery wall abnormality (noduli or intima-medial border blurring) was present in 19 of 20 participants (95%). The most present was the intima-medial blurring. (80% of participants). The noduli were present in 65% of study group, in almost 40% of these, they were considered as hyperechogenic. All these affections were predominantly in popliteal artery area (65%). The vast majority has bilateral affection. We find a mild correlation between these ultrasound findings and training load represented by annual kilometers and run hours. There was no association between these changes and lipid spectrum or CRP level., Conclusion: The subclinical lower limb artery changes, represented by intima-medial border blurring and non-atherosclerotic noduli were present in almost every amateur endurance runner. Despite the underlying mechanism is not understood, the increased training load seems to be one of the responsible factors., (© 2024. The Author(s).)

Background: Autologous vein is recommended for infrainguinal bypass due to improved freedom from occlusion compared to prosthetic graft. In patients without adequate vein, a vein adjunct at the distal anastomosis has been suggested to improve patency in small studies. This study aimed to determine if performance of a distal vein adjunct was associated with improved freedom from occlusion in below-knee popliteal and tibial bypasses compared to prosthetic bypass alone., Methods: A retrospective review of the Vascular Quality Initiative Infrainguinal Bypass database was conducted. Patients undergoing prosthetic-only and prosthetic with vein adjuncts were compared. Inclusion criteria included age ≥18 years, and bypass to below-knee popliteal or tibial vessels. Exclusion criteria included autologous vein conduits and prior interventions. Groups were further divided into below-knee popliteal and tibial subgroups., Results: A cohort of 3,939 patients underwent bypass to the below-knee popliteal artery, with 287 (7.3%) receiving vein adjuncts. More patients were male (68.8 vs. 57.8%, P < 0.001) and had higher rates of congestive heart failure (21.1 vs. 16.0%, P = 0.040) within the below-knee popliteal group. Two-year bypass occlusion was decreased in patients receiving vein adjuncts (11.6 vs. 17.1%, P = 0.004). A cohort of 2,378 patients underwent tibial bypass, with 473 (19.9%) receiving vein adjuncts. Within the tibial group, patients were similar in age, body mass index, race, comorbidities, and indications. Bypass occlusion (24.8 vs. 17.6%, P = 0.005) and amputation (20.5 vs. 15.9%, P = 0.048) rates at 2 years were worse for patients who did not receive a distal vein adjunct to tibial arteries., Conclusions: Distal vein adjuncts are associated with improved freedom from occlusion, amputation, major adverse limb events, and overall survival when compared to bypasses performed with prosthetic graft alone for tibial bypasses within the Vascular Quality Initiative. A vein adjunct was not associated with improved freedom from occlusion in below-knee popliteal bypasses. Consideration should be given to utilization of a distal vein adjunct to improve prosthetic bypass longevity and limb salvage for patients requiring tibial bypasses., (Copyright © 2024 Elsevier Inc. All rights reserved.)

During tibial plateau leveling osteotomy (TPLO), the laceration of the cranial tibial artery (LCTA) may occur, and the ligation of the cranial tibial artery might lead to impaired blood supply to the osteotomy site. The present case-control study aimed to evaluate the effect of LCTA on TPLO healing and the occurrence of perioperative complications. The incidence and predisposing factors to LCTA were also investigated. Fourteen cases experiencing LCTA were retrospectively enrolled from medical records of two veterinary teaching hospitals (LCTA group), whereas 28 randomly selected TPLOs that did not experience LCTA were included in the control group. Signalment data, proximal tibial epiphysis conformation, osteotomy features, perioperative complications, and bone healing were compared between the two groups. Bone healing was evaluated using the modified radiographic union scale for tibial fracture and the visual analog scale. The mean incidence was 9.6%. Bodyweight was significantly higher in the LCTA group compared to the control group (P = 0.009). Dogs belonging to the LCTA groups were significantly younger (P = 0.01). Intraoperative hypotension was significantly overreported in the LCTA group (P = 0.0001). None of the other variables differed significantly between the two groups. Dogs' size seems to be a predisposing factor, with dogs weighing >15 kg having 22 times more chance of experiencing LCTA. Due to the well-developed collateral blood supply of the canine hindlimb, LCTA and the closure of the cranial tibial artery did not appear to delay the radiographic bone healing or affect the incidence of perioperative complications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Endovascular interventions in infrapopliteal occlusive artery disease are becoming more complex, and this frequently tests the standard method of treatment, plain old balloon angioplasty (POBA). The potential that serration angioplasty could produce a more acceptable tibial artery lumen was assessed in this study., Aim: The aim of this single-center subgroup analysis was to compare acute angiographic results after endovascular treatment using the Serranator serration balloon catheter in patients participating in the PRELUDE-BTK trial with POBA of the infrapopliteal arteries. A secondary objective was to assess post-treatment hemodynamic improvements., Methods: Our center enrolled 15 subjects and treated 17 lesions within the multicenter prospective core laboratory-adjudicated PRELUDE-BTK study. A 25 lesions analyzed separately were treated with POBA and then compared with the Serranator subset. In both cohorts, lesions were treated with either plain angioplasty or Serranator as a stand-alone therapy; subsequent methods, such as drug elution technologies, were not used. Acute angiographic results were analyzed by the SynvaCor angiographic core laboratory. To assess volumetric flow rates, data were analyzed with a fluid flow simulation software and compared against Poiseuille's Law., Results: Final residual stenosis was 17.2%±8.2% in the Serranator group versus 33.7%±15.7% in the POBA group. The mean lumen diameter (MLD) gain for the Serranator group and the POBA group was 1.64±0.41 mm and 1.33±0.63 mm, respectively. The average atmospheric balloon inflation pressure was 5 ATM in the Serranator group versus 9 ATM in the POBA group. Neither group required a bailout stent; however, it was notable that there were significantly more chronic total occlusions (CTOs) treated in the Serranator group at 41.2% versus 12% in the POBA group. Regarding the effectiveness in improving hemodynamic blood flow for non-CTO lesions, the calculated average ratio of post-treatment to pre-treatment flow rates in the Serranator group was 238% than that for the POBA group. For CTO cases where pre-treatment flow rate was zero, final residual stenosis was used as the parameter for comparison. The Serranator group showed a 62% improvement in final residual stenosis over POBA., Conclusion: Endovascular treatment of the infrapopliteal arteries by use of the Serranator serration balloon provides a novel and promising method of action compared with standard balloon angioplasty and, thus, may have a leading role in complex below-the-knee arterial lesions., Clinical Impact: The Serranator device might help to adequately address issues with conventional routine techniques for the treatment of complex lesions in infrapopliteal arteries in patients with advanced stages of PAD and critical limb ischemia. Integrating modern technologies such as the Serranator balloon catheter into clinical routine is mandatory in order to gain a more favorable outcome in these severely diseased patients and, particularly, to reduce mortality and morbidity., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The uncertainty concerning the physiological effects of compression bandaging on the peripheral blood flow is a challenge for healthcare professionals. The main objective was to determine the haemodynamic impact on the distal posterior tibial artery after the application of a high-compression leg multicomponent bandaging system using 4D flow magnetic resonance imaging. Leg dominance disparities of the posterior tibial artery before and after the application of the compressive bandage were also analysed. Twenty-eight healthy female volunteers were recruited (mean: 25.71, standard deviation: 4.74 years old) through a non-probability convenience sampling. The 4D flow magnetic resonance imaging of the distal tibial posterior artery was performed in all participants, first under standard resting conditions and after the application of a compression bandage in the leg. When the strong compressive bandage was applied, the area of the assessed artery decreased by 14.2%, whilst the average speed increased by 19.6% and the flow rate increased by 184.8%. There were differences between the haemodynamic parameters of both legs according to dominance, being statistically significantly lower in the dominant leg. The application of strong compressive bandaging significantly increases the arterial flow and mean velocity in the distal segment of the posterior tibial artery, in healthy volunteers by 4D flow magnetic resonance imaging. In this study, leg dominance influenced some of the haemodynamic parameters. According to the results, leg compression bandages cannot be contraindicated in vascular ulcers with arterial compromise., (© 2024 The Author(s). International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Objective: Patients with diabetes mellitus (DM) are at increased risk for peripheral artery disease (PAD) and its complications. Arterial calcification and non-compressibility may limit test interpretation in this population. Developing tools capable of identifying PAD and predicting major adverse cardiac event (MACE) and limb event (MALE) outcomes among patients with DM would be clinically useful. Deep neural network analysis of resting Doppler arterial waveforms was used to detect PAD among patients with DM and to identify those at greatest risk for major adverse outcome events., Methods: Consecutive patients with DM undergoing lower limb arterial testing (April 1, 2015-December 30, 2020) were randomly allocated to training, validation, and testing subsets (60%, 20%, and 20%). Deep neural networks were trained on resting posterior tibial arterial Doppler waveforms to predict all-cause mortality, MACE, and MALE at 5 years using quartiles based on the distribution of the prediction score., Results: Among 11,384 total patients, 4211 patients with DM met study criteria (mean age, 68.6 ± 11.9 years; 32.0% female). After allocating the training and validation subsets, the final test subset included 856 patients. During follow-up, there were 262 deaths, 319 MACE, and 99 MALE. Patients in the upper quartile of prediction based on deep neural network analysis of the posterior tibial artery waveform provided independent prediction of death (hazard ratio [HR], 3.58; 95% confidence interval [CI], 2.31-5.56), MACE (HR, 2.06; 95% CI, 1.49-2.91), and MALE (HR, 13.50; 95% CI, 5.83-31.27)., Conclusions: An artificial intelligence enabled analysis of a resting Doppler arterial waveform permits identification of major adverse outcomes including all-cause mortality, MACE, and MALE among patients with DM., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

Background: The palpation method of posterior tibial artery cannulation has not yet been compared to ultrasound-guided posterior tibial artery cannulation in adults. This research examined whether using ultrasound to cannulate the posterior tibial artery enhances first-pass cannulation success and lowers total procedure time., Methods: In this randomized controlled experiment, 76 adult patients were included who were undergoing surgery under general anesthesia and required artery cannulation. Cannulation of the posterior tibial artery was performed utilizing either an ultrasound-assisted method (group U) or a palpation method (group P). Data were analyzed for cannulation success on the first attempt, number of cannulation attempts, assessment time, cannulation time, and total procedure time., Results: The P group had a considerably shorter mean assessment time than the U group [14.29 ± 2.79 s vs 20.89 ± 2.70 s; p < .001]. Moreover, cannulation time was substantially longer in the P (29.20 ± 12.60 s) than in the U group (15.90 ± 6.50 s) (p < .001). The total procedure time remained statistically more in the P group than in the U group (p = 0.007). The rate of successful posterior tibial artery cannulation on the first attempt was comparable between the two groups (63.2% in the U and 55.3% in the P group, respectively; p = .484)]., Conclusions: The posterior tibial artery may be a suitable alternative to arterial cannulation for individuals with multiple failed attempts or difficult access. The application of ultrasound during posterior tibial artery cannulation in adult patients is safe and feasible and accompanied by a reduction in cannulation and total procedure time. The rate of first-attempt successful posterior tibial artery cannulation was comparable between the two groups., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: Disclosures None.

Background: Ethylene diamine tetra-acetic acid (EDTA) is a chelating agent used to dissolve calcium deposits but evidence in decalcifying atherosclerotic lesions is limited., Aims: We assessed the feasibility and efficacy of EDTA delivered via porous balloon to target calcified lesions in cadaveric below-the-knee (BTK) arteries., Methods: Using porcine carotid arteries, EDTA concentration was measured in the arterial wall and outside the artery at the 0-, 0.5-, 4-, and 24-h circulation after the injection through a porous balloon. In cadaver BTK samples, the proximal and distal anterior tibial artery (ATA) and distal posterior tibial artery (PTA) were studied. EDTA-2Na/H2O or EDTA-3Na/H2O were administrated using a porous balloon, then circulated for 6 h for EDTA-3Na/H2O and 24 h for EDTA-2Na/H2O and EDTA-3Na/H2O. Micro-CT imaging of the artery segments before and after the circulation and cross-sectional analyses were performed to evaluate calcium burden., Results: In the porcine carotid study, EDTA was delivered through a porous balloon present in the arterial wall and was retained there for 24 h. In BTK arteries, cross-sectional analyses of micro-CT revealed a significant decrease in the calcium area in the distal ATA segment under 24-h circulation with EDTA-2Na/H2O and in the distal ATA segment under 24-h circulation with EDTA-3Na/H2O. The proximal ATA segment under 6-h circulation with EDTA-3Na/H2O showed no significant change in any parameters of calcium CONCLUSION: EDTA-3Na/H2O or EDTA-2Na/H2O with longer circulation times resulted in greater calcium reduction in atherosclerotic lesion. EDTA may have a potential therapeutic option for the treatment of atherosclerotic calcified lesions., (© 2024 Wiley Periodicals LLC.)

Background: Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma., Methods: A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3)., Results: Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < 0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = 0.59). T3 received greater blood transfusion volume (P = 0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P = 0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = 0.16), and amputation was not significantly predicted by arterial ligation in T1 (P = 0.08) or T2 (P = 0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P = 0.02), but other limb complication rates were similar., Conclusions: In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The objective of this study was to define the danger zone at which the anterior tibial artery (ATA) is at risk during anterolateral plating of the distal tibia using a novel 3D computed tomography angiography (CTA) modeling technique., Methods: 116 patients (232 lower extremities) who underwent lower extremity CTAs between April 2020 and April 2022 were identified. Those with lower extremity trauma, evidence of a previously healed tibial fracture, or poor visualization of the ATA were excluded. The remaining 150 lower extremities (92 patients) were modeled with an anterolateral distal tibia plate using Sectra IDS7 software. The distance of the ATA from bony landmarks was measured perpendicular to the level at which the vessel intersected the plate., Results: The ATA intersected the plate proximally at a mean distance of 10.5 cm (95% confidence intervals, 10.2-10.9) and at a mean distance of 4.6 cm (95% confidence intervals, 4.4-4.9) distally from the central tibial plafond. The ATA intersected with the plate as far distal as hole number 1 and as proximal as hole 14 of the plate. The greatest injury risk was associated with plate holes 3-8. In this region, the artery was at risk in 46-99 percent of specimens., Conclusions: The ATA is at risk when screws are placed percutaneously in an anterolateral distal tibia plate. The artery can be as close as 4.4 cm and as far as 10.9 cm proximal to the tibial plafond when crossing the plate, correlating to a risk of injury to the ATA at plate holes 1 through 14., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Tibial artery calcification (TAC) is correlated with an increased risk of amputation and mortality in patients with chronic limb-threatening ischemia (CLTI). The association between calcification characteristics and adverse limb events of CLTI. However, it has not been assessed. This study aims to assess the relationship between the characteristics of TAC based on computed tomography angiography (CTA) scans and postoperative outcomes in patients with CLTI undergoing infrapopliteal endovascular therapy., Methods: This was a retrospective study of patients who underwent infrapopliteal endovascular revascularization for CLTI and had a preoperative CTA scan. Based on CTA, TAC was divided into the following categories: annularity, thickness, continuity and severity. Cox regression models using generalized estimating equations were performed to assess the relationship between calcification characteristics and postoperative outcomes. The outcomes evaluated were the occurrence of all cause mortality (ACM) and unplanned amputation., Results: Among the 148 patients undergoing endovascular, there were 50 (33.8%) patients died and 26 (17.6%) patients underwent unplanned amputation. Annular calcification was more common in the ACM group than in the non-ACM group. No significant differences were found between the two groups with regard to the probability of calcification in the thickness and the continuity (P>0.05). Patients in the unplanned amputation group had significantly annular, thin and continuity calcifications (P<0.05) than those in the non-unplanned amputation group. The presence of annular calcification was an independent predictor of ACM (hazard ratio (HR), 3.186; 95% confidence interval (CI), 1.781-5.702; P<0.001) and unplanned amputation (HR, 3.739; 95% CI, 1.707-8.191; P<0.05)., Conclusions: Among patients with CLTI, the occurrence of annular calcification in the tibial artery are related to a greater chance of ACM and unplanned amputation in the postoperative period. The circumferential degree of TAC of the operated limb can be considered as a marker of clinical prognosis in this group of patients.

Aims: Though the number of patients with peripheral arterial disease (PAD) and critical limb ischemia (CLI) is increasing, few histopathological studies of PAD, particularly that involving below-the-knee arteries, has been reported. We analyzed the pathology of anterior tibial artery (ATA) and posterior tibial artery (PTA) specimens obtained from patients who underwent lower extremity amputation due to CLIMethods: Dissected ATAs and PTAs were subjected to ex-vivo soft X-ray radiography, followed by pathological examination using 860 histological sections. This protocol was approved by the Ethics Review Board of Nihon University Itabashi Hospital (RK-190910-01) and Kyorin University Hospital (R02-179)., Results: The calcified area distribution was significantly larger in PTAs than in ATAs on soft X-ray radiographic images (ATAs, 48.3% ±19.2 versus PTAs, 61.6% ±23.9; p＜0.001). Eccentric plaque with necrotic core and macrophage infiltration were more prominent in ATAs than in PTAs (eccentric plaque: ATAs, 63.7% versus PTAs, 49.1%; p＜0.0001, macrophage: ATAs, 0.29% [0.095 - 1.1%] versus PTAs, 0.12% [0.029 - 0.36%]; p＜0.001), histopathologically. Thromboembolic lesions were more frequently identified in PTAs than in ATAs (ATAs, 11.1% versus PTAs 15.8%; p＜0.05). Moreover, post-balloon injury pathology differed between ATAs and PTAs., Conclusions: Histological features differed strikingly between ATAs and PTAs obtained from CLI patients. Clarifying the pathological features of CLI would contribute to establishing therapeutic strategies for PAD, particularly disease involving below-the knee-arteries.

Background: Medial arterial calcification (MAC) is a vascular disease distinct from atherosclerosis. Recently, several studies have demonstrated that MAC is an important marker of cardiovascular events. We aim to assess the presence of MAC during ultrasound screening of lower-limb vasculature and its association with both cardiovascular (CV) and lower-limb events in patients with type-2 diabetes., Methods: A retrospective cohort study was conducted on 1119 patients with type-2 diabetes free from CV disease. A CV work-up, including vascular ultrasound, was performed for each patient. The presence of MAC was assessed on posterior tibial arteries and ankle-brachial index (ABI) was measured. Major acute CV events (MACEs) and lower-limb events (MALEs) were recorded as a composite endpoint for a 5-year period., Results: We identified MAC among 212 (18.9%) patients. The independent determinants of MAC were age and diabetic retinopathy. Over a period of 5 years, 125 MACEs and 22 MALEs occurred. MAC was significantly associated with the composite outcome MACE + MALE (HR = 1.94; 95% CI: 1.23, 3.08, p = 0.005) or with MACE (HR = 1.85; 95% CI: 1.16, 2.95, p = 0.010). Adjusted for ABI and diabetic foot wound, MAC remained a determinant of MALE (HR = 5.49; 95% CI: 2.19, 13.76, p < 0.001). Considering each ABI group, MAC was associated with both MACE and MALE in the normal ABI group., Conclusions: Ultrasound-detected MAC on tibial arteries seems to be a determinant of both CV and lower-limb events, independent from ABI. MAC helps to refine the CV risk in patients with normal ABI., Competing Interests: Declaration of conflicting interestsVictor Aboyans receives support from Amarin, AstraZeneca, Boehringer-Ingelheim, NovoNordisk. The other authors declare no conflicts of interest.

Background: Arterial catheterisation in children can be challenging and time-consuming. We aimed to compare the success rates of ultrasound-guided arterial catheterisation utilising the short-axis out-of-plane approach with dynamic needle tip positioning in the radial, dorsalis pedis, and posterior tibial arteries in paediatric patients. We also examined the factors influencing the catheterisation success using dynamic needle tip positioning., Methods: Paediatric patients (aged <3 yr) undergoing cardiac surgery were randomly assigned to three groups based on puncture sites: radial artery (Group R), dorsalis pedis artery (Group D), and posterior tibial artery (Group P). The first-attempt and overall success rates of arterial catheterisation were compared, followed by multiple logistic regression analysis (dependent variable: first-attempt success; independent variables: body weight, diameter and depth of the artery, targeted artery, and trisomy 21)., Results: The study included 270 subjects (n=90 per group). There was no significant difference in the first-attempt (Group R: 82%, Group D: 76%, and Group P: 81%) and overall success rates (Group R: 94%, Group D: 93%, and Group P: 91%) among the three groups. The diameter of the artery (per 0.1 mm) (odds ratio: 1.32, 95% confidence interval: 1.09-1.60) and trisomy 21 (odds ratio: 0.43, 95% confidence interval: 0.20-0.92) were independent predictors of first-attempt success or failure., Conclusion: The first-attempt and overall success rates of arterial catheterisation of the dorsalis pedis and posterior tibial arteries were not inferior to those in the radial artery when using dynamic needle tip positioning. These two lower extremity peripheral arteries present viable alternative catheterisation sites in paediatric patients., Clinical Trial Registration: UMIN000042847., (Copyright © 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Pseudoaneurysms are false aneurysms that consist of turbulent blood flow between the outside layers of the arterial wall, the tunica media and tunica adventitia. Typically, pseudoaneurysms develop after injury to an artery, most often as a result of blunt trauma. Femoral pseudoaneurysms can also develop after catheter-based vascular interventions due to laceration of the artery from access needles, insufficient time or pressure held at the access site after the procedure, amongst other causes. Rarely, arterial injury during orthopedic pinning procedures has been known to cause pseudoaneurysms. There are only two documented cases within the literature in which a patient underwent closed intermedullary nailing of a proximal tibia fracture after trauma and developed an anterior tibial artery pseudoaneurysm. There are few reports of pseudoaneurysm development as the result of external fixation device placement presumably caused by the inability to directly visualize internal anatomy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Delivery of mesenchymal stem cells (MSC) via intravascular techniques to treat diffuse and/or inaccessible soft tissue injuries has grown in popularity. The purpose of the current prospective, analytical pilot study was to utilize CT to validate this novel technique and provide additional evidence to support its use for injectate delivery to specific soft tissue structures. Of particular interest was the proximal suspensory ligament, which presents a challenging injection target. Six adult horses without lameness underwent CT of the distal hindlimbs. Scans were obtained prior to ultrasound-guided catheterization of the cranial tibial artery, in addition to early and delayed scans acquired following intra-arterial contrast administration. Region of interest analysis of the superficial and deep digital flexor tendons and suspensory ligament was used to assess contrast enhancement within these structures. Linear mixed models were used to determine statistical significance. Significant (P < 0.05) mean contrast enhancement was seen in all postinjection time points in all soft tissue structures of interest. This indicates that ultrasound-guided injection of the cranial tibial artery results in perfusion of injectate throughout the distal hind limb, including the major soft tissue structures of the metatarsus. This provides further support for this technique as a method of MSC delivery to multifocal or inaccessible injury of these structures, including the proximal suspensory ligament., (© 2023 The Authors. Veterinary Radiology & Ultrasound published by Wiley Periodicals LLC on behalf of American College of Veterinary Radiology.)

Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: Traditional research methods have limited the application of anterior tibial artery perforator flap due to incomplete knowledge of the perforator. This study aimed to investigate the feasibility of three-dimensional digitalized virtual planning of free anterior tibial artery perforator flap for repairing soft tissue defects in extremities., Methods: A total of 11 patients with soft tissue defects in extremities were included. The patient underwent computed tomography angiography (CTA) of bilateral lower limbs, and then the three-dimensional models of bones, arteries, and skin were constructed. Septocutaneous perforators with appropriate length and diameter were selected to design anterior tibial artery perforator flaps in software, and the virtual flaps were superimposed onto the patient's donor site in a translucent state. During the operation, the flaps were dissected and anastomosed to the proximal blood vessel of the defects as designed., Results: Three-dimensional modeling showed clear anatomical relationships between bones, arteries, and skin. The origin, course, location, diameter, and length of the perforator obtained during the operation were consistent with those observed preoperatively. Eleven anterior tibial artery perforator flaps were successfully dissected and transplanted. Postoperative venous crisis occurred in one flap, partial epidermis necrosis occurred in another flap, while the remaining flaps completely survived. One flap was treated with debulking operation. The remaining flaps maintained aesthetic appearance, which did not affect the function of the affected limbs., Conclusions: Three-dimensional digitalized technology can provide comprehensive information on anterior tibial artery perforators, thus assisting in planning and dissecting patient-specific flaps for repairing soft tissue defects in extremities., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Summary: The tibial nerve is bound tightly to the posterior tibial artery in the tarsal tunnel where expansion capacity is limited. Therefore, the nerve may be vulnerable to, and damaged by chronic pulsatile trauma from an atypically positioned overriding artery, labeled "punched-nerve syndrome". In this article, we present a 49-year-old woman who presented with two months of severe burning pain in the left medial ankle and sole of the foot without antecedent trauma. Neurological examination identified dysesthetic sensation to light touch in the left medial sole of the foot, and both active and passive dorsiflexion worsened the painful paresthesia. Nerve conduction studies demonstrated a reduced left medial plantar mixed nerve action potential amplitude, 50% less than the right. High-resolution ultrasound (HRUS) showed an increased left tibial nerve cross-sectional area of 26 mm2 (normal <22.3 mm2) at the level of the ankle with side-to-side difference of 6 mm2 (normal <5.7 mm2). The distal tibial nerve and its medial plantar branch were atypically positioned immediately deep to the left posterior tibial artery and abnormally flattened with focal enlargement of the nerve on longitudinal view. Dynamic analysis demonstrated the nerve being compressed with each pulsation of the tibial artery immediately above. Active dorsiflexion of the ankle narrowed the space underneath the flexor retinaculum resulting in further compression of the nerve against the artery. In conclusion, HRUS as an adjunct to electrophysiological studies identified punched-nerve arterial compression as an etiology of tarsal tunnel syndrome., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 by the American Clinical Neurophysiology Society.)

Objective: This study aimed to describe the course, branches, and variances of the posterior tibial artery, which provides the arterial supply of the plantar surface of the foot, starting from the tarsal tunnel level to provide descriptive information for all surgical interventions, diagnostic radiological procedures, and promising endovascular therapies in the tarsal region., Methods: In this study, a dissection of 48 feet was performed on 25 formalin-fixed cadavers (19 males and 6 females). Surgical instruments and a digital caliper were used for dissection and measurements, and the critical structures were recorded by a Canon 250D camera to be illustrated later., Results: All parameters were significantly longer in male cadavers compared to females. According to the correlation analysis, while there was a significant and robust correlation between the axial line and pternion-deep plantar arch (R=.830, P .05), a moderate correlation was found between the axial line and sphyrion-bifurcation (R=.575; P < .05), axial line and deep plantar arch-2nd interdigital commissure (R=.457; P < .05), and sphyrion-bifurcation and pternion-deep plantar arch (R=.480; P < .05). Variation in any branch of the posterior tibial artery was observed in 27 of the 48 studied sides., Conclusion: In our study, the branching and variability of posterior tibial artery on the plantar surface of the foot were described in detail with the determined parameters. In conditions that cause tissue and function loss and require reconstruction, such as diabetes mellitus and atherosclerosis, the most critical factor in increasing treatment success is a better understanding of the region's anatomy.

Case: We report a unique anatomical case of an anomalous course of the posterior tibial artery found on dissection during the posterolateral approach to the ankle. To the best of our knowledge, no such case has been documented., Conclusion: The vascular bundle consistent with that of the posterior tibial artery and vein was encountered in the far lateral aspect of the deep posterior compartment, which suggests physicians should proceed with caution when performing the posterolateral approach to the ankle so as to avoid iatrogenic injury of this named anatomic structure., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C17)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Pilon fractures of the distal tibia are usually the result of a high-energy trauma and can affect seriously the arterial vasculature carrying an increased risk of amputation at the malleolar level or higher. Such cases represent a challenge for the orthopedic surgeons and a multidisciplinary approach is mandatory in order to salvage the threatened limb. We present an unusual case of a closed pilon fracture with injury of all tibial vessels leading to acute limb threatening ischemia. The patient was treated successfully with external fixation and a short tibial-pedal bypass with use of an autologous reversed saphenous vein graft. This example dictates how a distal leg fracture can be dramatic and that awareness of vascular examination coupled with high suspicion of vascular damage can be limb-saving. Multidisciplinary approach is warranted since the topology and complexity of the ankle lesions necessitate staged orthopedic reconstructions with tibio-distal bypass and appropriate skin coverage of the distal anastomosis.

Tarsal tunnel syndrome is a neuropathic compression of the tibial nerve and its branches on the medial side of the ankle. It is a challenging diagnosis that constitutes symptoms arising from damage to the posterior tibial nerve or its branches as they proceed through the tarsal tunnel below the flexor retinaculum in the medial ankle, easily forgotten and underdiagnosed. Neural compression by vascular structures has been suggested as a possible etiology in some clinical conditions. Tibial artery tortuosity is not that rare, but only that it affects the nerve can cause tarsal tunnel syndrome. Therefore, a study care must be taken to avoid false-positive errors.

Background: To examine the feasibility of using pulsatility index-adjusted (PI) flow equations to accurately characterize blood volume flow changes using Doppler technique in patients with peripheral artery disease (PAD) before and after percutaneous transluminal angioplasty (PTA)., Methods: PTA was performed on 17 PAD patients (23 target vessels treated, 16 anterior tibial arteries, and 7 posterior tibial arteries). Arterial diameter, peak systolic velocity, PI, time-averaged mean velocity, and measured volume flow (MVF) of dorsalis pedis artery (DPA) and common plantar artery (CPA) were measured with duplex Doppler ultrasound before and after PTA. PI-adjusted volume flows (PIVF) were calculated as part of the MVF/PIVF relative percentage metric., Results: Significant changes (p < 0.001) of the MVF (mean: 33.0 mL/min, range: -20.9-102.2 mL/min) and MVF/PIVF relative percentages (mean: 51.8, range: 5.1-127.2%) in the DPA existed between before and after PTA, whereas no significant changes could be found in the CPA (mean:10.9 mL/min, p = 0.148 and mean: 21.3%, p = 0.146, respectively). Of the 7 treated posterior tibial arteries, the increments of the MVF/PIVF (mean: 60.4%, p = 0.033) was significant but not in the MVF (mean: 26.5 mL/min, p = 0.125). The ankle-brachial index also showed non-significant changes (p = 0.081). All PI-adjusted results matched clinical observations after blood flow restoration., Conclusion: No conclusions can be drawn from the comparison of actual measured volume flow between before and after PTA. However, using the MVF/PIVF relative percentage allows for a more objective framework upon which to base clinical observations and provides clarity in situations where direct measurement provides a counter-intuitive or contradictory picture., Competing Interests: Conflicts of interest: The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article., (Copyright © 2022, the Chinese Medical Association.)

Rationale: Vascular involvement manifests as aneurysms, stenosis, and arteriovenous malformations in patients with type I neurofibromatosis (NF-I). Aneurysms are rare; however, the renal artery is the most common site. Herein, we report a rare case of stent graft placement in an anterior tibial artery (ATA) pseudoaneurysm in a patient with NF-I., Patient Concerns: A 52-year-old woman with NF-1 was admitted to the emergency room with painful swelling in the left lower leg. At presentation, the patient's blood pressure was 100/60 mmHg and the hemoglobin level was 9 g/dL., Diagnoses: Computed tomography scan revealed a small aneurysm arising from the left ATA and an adjacent large hematoma., Intervention: Stent graft placement was performed to treat ATA pseudoaneurysm., Outcomes: After stent graft placement, the aneurysm disappeared and the distal flow was patent through the ATA., Lessons: Stent graft placement should be considered as another option for endovascular treatment in patients in whom coil embolization or surgery cannot be performed., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

PURPOSE We aimed to demonstrate the feasibility of ultrasound (US)-guided retrograde tibial access through chronically occluded tibial arteries as a bailout endovascular recanalization procedure in patients with critical limb ischemia (CLI). METHODS Fifty-one CLI patients with failed conventional antegrade tibiopedal recanalization required retrograde tibiopedal access in the same session. In all of these patients, the target tibial artery was chronically occluded in at least the distal half of the cruris. Access attempts were made under real-time US by a single operator experienced in image-guided vascular access procedures. Fluoroscopy was used only as an adjunct during advancement of a 0.018 inch guidewire. If access to the artery was successful by the retrograde route, the occluded artery was usually predilated with a 2 mm balloon, and the standard endovascular treatment was mostly performed through the antegrade route. RESULTS Patients had athereosclerosis (n=35) or Buerger's disease (n=32) and presented with Rutherford category IV and category V. Successful placement of a guidewire in the occluded artery lumen was achieved in 81% of all patients, whereas, treatment success, i.e. angiographic demonstration of in-line flow at the end of procedure, was achieved in 49%. No significant procedure-related complications were observed. Of 33 limbs with initially successful endovascular treatment, 6 required minor and 1 required major amputation during follow-up. CONCLUSION US-guided retrograde access through completely occluded tibial arteries is difficult but feasible. Half of the tibial arteries that could not be recanalized otherwise were converted to successful recanalization by this method.

Objective:  To illustrate the arterial vascularity of the proximal tibia three-dimensionally and to evaluate the impact of fragment rotation on the cranial tibial artery by tibia plateau levelling osteotomy (TPLO)., Methods:  Radiographic angiography and computed tomography (CT) were performed on 12 pelvic limbs from six large-breed canine cadavers before and after TPLO. Three-dimensional (3D) models of the stifle, including osseous and vascular structures, were obtained, and the integrity of the cranial tibial artery was assessed. Post-TPLO CT images were used to analyze compression of the cranial tibial artery by the rotated fragment., Results:  The uncompressed cranial tibial artery caliber, measured proximally and distally to the osteotomy, was 9.52 mm 2 (6.07-18.90 mm 2 ). In all adequately rotated fragments, the mean caliber of the artery on the level of the osteotomy was 1.57 mm 2 (0.89-2.93 mm 2 ) after TPLO. This represented a significant decrease of approximately 81%. Only slight cross-sectional area decrease (8.8%) was seen in one limb, which was revealed to have insufficient fragment rotation (2.83 mm). Another limb only showed signs of stretching of the artery (31.51%), which was under-rotated and medially displaced. Pre-TPLO 3D reconstructions were mainly consistent with previous anatomic studies except for the distance between tibial cortex and cranial tibial artery, which appeared closer., Conclusion:  Sufficient fragment rotation leads to compression of the cranial tibial artery. Intraoperative hemorrhage can be caused by laceration of the main cranial tibial artery or by multiple small branches reaching craniolaterally., Competing Interests: The programs to perform model construction were financially supported by ZIM (Zentrales Innovationsprogramm Mittelstand) and Frank Goblet, Steinbeis-Innovationszentrum Systemlösungen in Mess- und Automatisierungstechnik Mannheim declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. This script is part of a dissertation., (Thieme. All rights reserved.)

The anterior tibial artery (ATA) is the most critical anatomical structure at risk at the distal border of the posterolateral approach to the tibial plateau. This study aimed to use available lower extremity digital subtraction angiography (DSA) images to determine the distal safe limit of this approach by measuring the distance from the tibial joint line to the ATA where it pierces the interosseous membrane. Tibial plateau mediolateral width (TP-ML-W) and the perpendicular distances from the ATA to the tibial joint line and fibular head were measured on DSA images in 219 lower extremities. To normalize the distances according to the tibial dimensions, each distance was divided by the TP-ML-W, and a ratio was obtained. Popliteal artery branching pattern was categorized according to the classification proposed by Kim et al. Comparative analysis between right and left extremities, genders, and anatomical variations were performed. There were 102 male and 26 female subjects with a mean age of 60.7 ± 15.7 years (range, 17-92 years). Ninety-one subjects had bilateral lower extremity DSA; thus, a total of 219 extremities were analyzed. The TP-ML-W was wider in male (78.3 ± 7.0) than female (70.5 ± 7.3) subjects ( p  = 0.001). The ATA coursed through the interosseous membrane at 50.9 ± 6.9 mm (range, 37.4-70.2 mm) distal to the tibial plateau joint line, and it was 66.5 ± 7.2% of the TP-ML-W. The ATA coursed through the interosseous membrane at 36.5 ± 6.0 mm (range, 21.9-53.8 mm) distal to the fibular head, and it was 47.7 ± 6.6% of the TP-ML-W. All measured variables were similar between the regular branching pattern of the popliteal artery (type 1A) and other observed variations among male subjects. The safe length of dissection in the posterolateral approach is average 66.5% (range, 45.7-86.7%) of the TP-ML-W. This ratio is valid for both genders. The use of a ratio instead of a distance, which is subject to personal variations, seems to be more logical and practical for planning this surgery, but the wide range should still not be ignored., Competing Interests: None declared., (Thieme. All rights reserved.)

Competing Interests: Competing interests: None declared.

BACKGROUND Acute arterial occlusion after total knee arthroplasty (TKA) is a rare but occasionally limb-threatening complication. Successful outcomes of surgical treatment for acute arterial occlusion after TKA have been frequently reported in the literature; however, few reports have described conservative treatment. This case report describes the successful conservative treatment of popliteal artery occlusion after TKA. CASE REPORT We report 2 cases of popliteal artery occlusion after TKA that were managed with conservative treatment. In Case 1, a 68-year-old woman presented with a weak dorsalis pedis pulse in the foot and weakness to dorsiflexion of the toe on the operative side immediately after TKA. The operative lower extremity arterial ultrasonography and computed tomography angiography demonstrated the popliteal artery occlusion. In Case 2, a 79-year-old woman presented a cold right foot and lack of popliteal and dorsalis pedis pulse in the operated extremity immediately after TKA, and Doppler ultrasound did not reveal a flow for the dorsalis pedis artery. In both patients, urgent angiographies showed popliteal artery occlusion, and blood flow was observable in the anterior tibial, peroneal, and foot arteries collateral perfusion. Thus, conservative treatments were chosen, and anticoagulant and vasodilator therapies were undergone in both patients. At 6 months after surgery, they were able to walk without intermittent claudication. CONCLUSIONS Conservative treatment can be a good option for popliteal artery occlusion after TKA in cases of rich collateral circulation.

Objective: To explore the feasibility of peroneal perforating chimeric tissue flap in repairing the composite defects of calf and heel based on lower limb angiography, and the clinical effect., Methods: The digital subtraction angiography images of lower limbs of 50 patients met the selection criteria between May 2011 and October 2014 were used as the research object to observe the course of peroneal artery and its perforating vessels. Based on the observation results, between April 2015 and October 2020, the peroneal perforating chimeric tissue flap was designed to repair 7 cases of composite defects of the calf and heel. There were 5 males and 2 females with an average age of 38 years (range, 25-55 years). The causes of injury included traffic accident in 4 cases, falling from height in 2 cases, and machine strangulation in 1 case. There were 5 cases of calf skin defect and tibial defect. The size of skin defect ranged from 5 cm×3 cm to 11 cm×7 cm, and the length of bone defect was 5-8 cm. There were 2 cases of heel skin defect and calcaneal defect. The sizes of skin defects were 5.0 cm×4.0 cm and 7.5 cm×6.5 cm, and the bone defects were 3.0 cm×2.6 cm and 4.0 cm× 3.0 cm. For the calf defect, the size of skin flap ranged from 6 cm×4 cm to 12 cm×8 cm, and the length of the fibula was the same as that of the tibial defect. For the heel defect, the sizes of the skin flaps were 8.5 cm×5.5 cm and 13.0 cm×5.0 cm, and the lengths of the fibulae were 10 cm and 12 cm. Free transplantation was performed in 5 cases and pedicle transplantation in 2 cases. The wound at donor site was repaired with skin grafting or sutured directly., Results: The peroneal artery ran close to the fibula 7.25-8.40 cm below the fibula head and send out 5-7 perforating vessels, with an average of 6.5 vessels. Perforating vessels mainly appeared in four places, which were (9.75±0.91), (13.21±0.74), (18.15±1.22), and (21.40±0.75) cm below the fibular head, with the occurrence rates of 94%, 90%, 96%, and 88%, respectively. Clinical application of 7 cases of peroneal perforating chimeric tissue flap all survived, all wounds healed by first intention. The skin graft at donor site survived and the incision healed by first intention. All patients were followed up 6-36 months, with an average of 12 months. Peroneal perforator chimeric tissue flap had good shape and soft texture. X-ray films showed that the bone graft healed well, and the healing time was 6-11 months (mean, 7 months). No obvious bone resorption was observed during follow-up. Five patients had no pain when walking, and 1 had mild pain with claudication. Postoperative heel ulcers formed in 1 case and healed after wearing custom plantar pressure dispersing shoes. At 6 months after operation, 2 patients were rated as grade Ⅳ and 5 patients as grade Ⅴ according to Holden walking function score., Conclusion: The peroneal perforating vessel distribution is constant and the peroneal perforating chimeric tissue flap is safe and reliable for repairing the composite defects of calf and heel.

Purpose: To compare retrograde plantar-arch and transpedal-access approach for revascularization of below-the-knee (BTK) arteries in patients with critical limb ischemia (CLI) after a failed antegrade approach., Materials and Methods: Retrospectively we identified 811 patients who underwent BTK revascularization between 1/2014 and 1/2020. In 115/811 patients (14.2%), antegrade revascularization of at least 1 tibial artery had failed. In 67/115 (58.3%), patients retrograde access to the target vessel was achieved via the femoral access and the plantar-arch (PLANTAR-group); and in 48/115 patients (41.7%) retrograde revascularization was performed by an additional retrograde puncture (TRANSPEDAL-group). Comorbidities, presence of calcification at pedal-plantar-loop/transpedal-access-site, and tibial-target-lesion was recorded. Endpoints were technical success (PLANTAR-group: crossing the plantar-arch; TRANSPEDAL-group: intravascular placement of the pedal access sheath), procedural success [residual stenosis <30% after plain old balloon angioplasty (POBA)], and procedural complications limb salvage and survival. Correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were tested., Results: Technical success was achieved in 50/67 (75%) patients of the PLANTAR-group and in 39/48 (81%) patients of the TRANSPEDAL-group (p=0.1). Procedural success was obtained in 23/67 (34%) patients of the PLANTAR-group and in 25/48 (52%) patients of the TRANSPEDAL-group (p=0.04). In 14/49 (29%) cases with calcification at the pedal-plantar loop, technical success was not achieved (p=0.04), and in 33/44 (75%) patients with calcification at the tibial-target-lesion, procedural success was not attained (PLANTAR-group) (p=0.026). In the TRANSPEDAL-group, correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were not observed (p=0.2/p=0.4). In the PLANTAR-group, minor complications occurred in 13/67 (19%) and in the TRANSPEDAL-group in 4/48 patients (8%) (p=0.08). Limb salvage at 12 (18) months was 90% (82%) (PLANTAR-group; 95%CI 15.771-18.061) and 84% (76%) (TRANSPEDAL-group; 95%CI 14.475-17.823) (Log-rank p=0.46). Survival at 12 (18) months was 94% (86%) (PLANTAR-group; 95%CI 16.642-18.337) and 85% (77%) (TRANSPEDAL; 95%CI 14.296-17.621) (Log-rank p=0.098)., Conclusion: Procedural success was significantly higher using the transpedal-access approach. Calcifications at pedal-plantar loop and target-lesion significantly influenced technical/procedural failure using the plantar-arch approach. No significant difference between both retrograde techniques in terms of feasibility, safety, and limb salvage/survival was found.

Objective: Atherectomy has become commonplace as an adjunct to interventional treatments for peripheral arterial disease, but the procedures have been complicated by risks including distal embolization and arterial perforation. This study aimed to examine the safety and effectiveness of a novel atherectomy system to treat femoropopliteal and below-knee peripheral arterial disease., Methods: The Revolution Peripheral Atherectomy System (Rex Medical LP, Conshohocken, Pa) was studied in 121 patients with 148 femoropopliteal and below-knee lesions, enrolled at 17 United States institutions. Technical success was defined when the post-atherectomy angiographic stenosis was ≤50%, as assessed by an independent core laboratory. Major adverse events were adjudicated by an independent Clinical Events Committee., Results: Among 148 site-identified target lesions in 121 patients, 21.4% were in the superficial femoral artery, 13.7% involved the popliteal artery, and 67.9% were in tibial arteries; 3.1% involved more than one segment. Technical success was 90.2%, with stenoses decreasing from 73% ± 19% at baseline to 42% ± 14% after atherectomy. Adjunctive treatment after atherectomy included angioplasty with uncoated balloons in 91%, drug-coated balloons in 11%, bare stent deployment in 8%, and drug-eluting stent placement in 3%. Procedural success (<30% residual stenosis) was achieved in 93.7% of target lesions. Complications during the procedure included one target vessel perforation and two distal embolizations; each of which were adjudicated by the Clinical Events Committee as unrelated to the device and were not visualized angiographically by the core laboratory. Freedom from major adverse events was 97.3% through 30 days. The Kaplan-Meier estimates of primary, assisted primary, and secondary patency were 81.6%, 87.7%, and 91.6% at 6 months, respectively., Conclusions: The use of the Revolution Peripheral Atherectomy System was associated with few procedural complications and a high rate of success at the index procedure and through 6 months., (Copyright © 2021. Published by Elsevier Inc.)

Objectives: The posterolateral approach to the distal tibia is commonly used for stabilisation of ankle fractures as it allows good visualisation and direct reduction of the posterior distal tibia and malleolar fragments. This approach can also be used for internal fixation of an associated lateral malleolus fracture. The aim of our study is to describe the surgical anatomy of the peroneal artery (PA) in relation to the tibial plafond and the distal fibula; thereby suggesting a safe zone during proximal dissection of posterolateral approach., Methods: Using Computed Tomography Angiographic (CTA) study, the course of the PA in relation to the tibial plafond and distal fibula was analysed in 142 lower limbs (bilateral limbs of 71 adult patients; 43 males and 28 females). Axial, coronal, and sagittal CT sections were cross-linked to specify the position of the PA. The PA course was identified and the level of its distal bifurcation over the tibia was marked. Perpendicular measurements were made from this point to the tibial plafond and tip of distal fibula., Results: The PA bifurcated distally at mean 58.3±24.2mm (SD) (range: 37.0-115.0mm) proximal to the right tibial plafond and mean 81.9±24.4mm (range: 54.0-137.0mm) from the right distal fibular tip. In the contralateral side, the PA bifurcated at mean 57.9±23.3mm (range: 36.0-125.0mm) proximal to the left tibial plafond and 81.8±23.9mm (range: 54.0-147.0mm) from the left distal fibular tip. The difference between the right and the left side of distal bifurcation point diameter of the same patient was assessed, range (0.0-58.0mm) with median 2.0mm and IQR 10.0mm. Three different PA vasculature patterns were identified., Conclusions: It is important for surgeons to be aware of the surgical anatomy of PA to avoid inadvertent injury during posterolateral approach to distal tibia. The PA may bifurcate as close as 36mm from the tibial plafond with possible variation bilaterally. Therefore, special attention needs to be considered by the operating surgeon while dissecting in this region due to the wide anatomical variation in vasculature. However, once the PA is mobilised, any fixation modality including posterior buttress plate could be safely performed., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interest. This includes any financial or personal relationships that could inappropriately influence our work., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: We conducted a prospective evaluation of microperfusion parameters after tibial bypass surgery was performed. Differences between grafts with occlusions during follow-up and patent grafts were analyzed in relation to the pedal arch quality., Methods: Patients receiving tibial bypass grafts for chronic limb-threatening ischemia from 2019 to 2020 were included. Assessment of microcirculation (parameters: hemoglobin oxygen saturation [sO 2 ] and flow) was done by laser Doppler flowmetry and white light spectrometry (oxygen-to-see), supine and in elevation, whereas the macrocirculation was evaluated by the ankle-brachial index and duplex ultrasound examination. The quality of run-off was graded for each patient. Measurements were performed preoperatively, 1 day postoperatively, and after 6 months. Patients with graft occlusions during follow-up (OCCLUDED) and patients without occlusions (OPEN) were compared., Results: We included 42 patients (13 women, 29 men; mean age, 76.1 years; range, 60-89 years) were included. The patency of all grafts 1 day after the operation was confirmed by ultrasound examination. The overall analysis of the microcirculation showed significant changes in both the supine and elevated leg position between measurements taken preoperatively, 1 day after the operation, and after 6 months for the parameters sO 2 and FLOW (sO 2 supine, P = .001; sO 2 elevated, P < .001; FLOW supine, P < .001; FLOW elevated, P < .001). The comparison of the values 1 day after the operation yielded significantly decreased microperfusion parameters (both O 2 and FLOW) in the group that developed bypass occlusion in the later follow-up period (sO 2 supine: OCCLUDED, 35.7% [7.3-65.0] and OPEN, 48.7% [25.0-72.3] P = .011; FLOW supine: OCCLUDED, 27.7 A.U. [12.7-52.7] and OPEN, 57.3 A.U. [16.0-106.7], P = .008). No significant differences in the severity of the arch impairment was found between the OPEN and OCCLUDED groups (P = .651). Absolute values of the parameters sO 2 and flow showed no correlation with the pedal arch classification., Conclusions: Significantly poorer microperfusion was detected postoperatively in patients with later occurrence of graft occlusions despite patent grafts on the first postoperative day. Microperfusion measurements might be a possible tool for the prediction of graft failure., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Case: A 29-year-old woman presented with a low-energy, minimally displaced pilon fracture with progressive pain and paresthesias in the affected foot, ultimately requiring open reduction and internal fixation. Intraoperatively, the deep peroneal nerve and anterior tibial artery and vein were entrapped within the fracture. After freeing the bundle and fixing the fracture, the paresthesias improved and ultimately resolved., Conclusion: Injury to the anterior leg compartment neurovascular structures should be considered in low-energy, minimally displaced pilon fractures. In this instance, progressive neurologic symptoms not consistent with the radiographic findings indicated the patient for surgical exploration and fixation., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B762)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Fibular flaps have been widely used for mandibular and maxillary reconstructions. On occasion, anatomical variants of fibular arteries (FA) will be encountered., Purpose: Although anatomical variants of FA during fibular harvest have been reported, controversy exists regarding whether simple color Doppler ultrasonography (CDU) and physical examinations (PE) are sufficient for early preoperative detection., Material and Methods: A 10-year retrospective analysis in our department was performed to find the patients with various FA anomalies confirmed by computed tomography angiography (CTA) or intraoperative findings., Results: A total number of 19 FA anomalies were found either pre- or intraoperatively in 16 patients, in whom three cases were with bilateral FA variants. Type IIIC variants, also called arteria peronea magna (great peroneal artery), were confirmed in two legs, while the majority (13 legs) had type IIIA hypoplastic/aplastic posterior tibialis arteries (PTA). Four legs had new type IIID (low FA and PTA bifurcations). Preoperative CDU and PE only suspected anomalies in two legs. Six cases proceeded with using the affected fibulas, within whom vascular grafts were used in half of them for lengthening the FA pedicle. Local ischemia, partial soleus muscle necrosis, and claudication were reported in one., Conclusions: Routine CTA before every fibular harvest, rather than simple PE and CDU, should be added for screening contraindications and ensuring safety for fibular flap harvest.

The medial plantar artery (MPA) is often sacrificed as the vascular pedicle of the medial plantar flap (MPF). However, for patients with ankle soft tissue defect caused by traffic accident, the anterior tibial artery (ATA) could be damaged and the blood supply of the distal foot would only come from the MPA and the lateral plantar artery (LPA). In this case, sacrificing the MPA for the MPF means that the LPA will become the mainly source of blood supply of the distal foot. Whether the blood supply of the distal foot is adequately guaranteed remains to be discussed. A total of seven patients with ankle soft tissue defect and ATA injury were enrolled in the study. The digital subtraction angiography (DSA) was performed to observe the hemodynamics of the ipsilateral foot. The MPF was harvested only when the foot arterial network consisting of the MPA, the LPA, the deep plantar arch, and the deep plantar artery of DPA, and the blood redistribution existed. DSA results showed the blood from the posterior tibial artery was redistributed to the ipsilateral foot and the MPA is not the dominant artery in the foot. Seven MPFs were harvested, and all flaps survived completely. No complications, such as pain, ulcer, and necrosis, occurred in the ipsilateral toes. The DSA could accurately and intuitively evaluate the hemodynamics of foot in patients with ATA injury. The DSA data and clinical practice proved that the ATA injury is not the contraindication of the MPF., (Copyright © 2021 Elsevier Ltd. All rights reserved.)