Acute anterior tibial artery occlusion diagnosis and treatment

From the Guidelines

Acute anterior tibial artery occlusion diagnosis and treatment should be promptly addressed with emergent evaluation and revascularization to prevent limb loss.

Diagnosis

• The diagnosis of acute limb ischemia (ALI) due to acute anterior tibial artery occlusion requires timely recognition of symptoms such as a cold, painful, and/or numb limb 1.
• Invasive digital subtraction arteriography (DSA) is the gold standard for diagnosing ALI, as it permits simultaneous treatment of acute arterial occlusion 1.
• Noninvasive imaging with MRA or CT angiography may also be appropriate before treatment, especially when the diagnosis of ALI is in doubt or where DSA is unavailable 1.

Treatment

• Patients with acute limb ischemia and a salvageable extremity should undergo an emergent evaluation that defines the anatomic level of occlusion and that leads to prompt endovascular or surgical revascularization 1.
• The treatment approach depends on the category of ALI, with category IIb limbs requiring immediate revascularization to prevent irreversible damage 1.
• Prompt treatment is crucial to successful outcomes, and delays in treatment can result in irreversible damage and limb loss 1.

From the Research

Diagnosis of Acute Anterior Tibial Artery Occlusion

• Diagnostic angiogram is used to reveal anterior tibial artery (ATA) occlusion with severe calcification 2
• Angiographic findings of occluded isolated tibial artery after blunt trauma to the leg can be used for diagnosis 3
• Clinical and imaging findings, such as severe osteoarthritis and multiple osteochondromas, can be used to diagnose ATA occlusion after total knee arthroplasty 4

Treatment of Acute Anterior Tibial Artery Occlusion

• Subintimal angioplasty can be attempted using a 0.014-inch hydrophilic guidewire, but may be unsuccessful due to severe calcification 2
• Retrograde approach using surgical cutdown technique can be used for limb salvage in cases of critical limb ischemia with severely calcified tibial occlusive disease 2
• Percutaneous transfemoral placement of Gianturco coils can be used to treat pseudoaneurysm and arteriovenous fistula that evolve from an occluded anterior tibial artery 3
• Stent-apposition salvage can be used to treat an anterior tibial artery after inadvertent angioplasty balloon retention during CTO revascularization 5
• Conservative treatment can be appropriate for ATA occlusion after total knee arthroplasty, with pain relief and recovery of knee range of motion 4
• Retrograde proximal anterior tibial artery access can be used for treating femoropopliteal segment occlusion when antegrade recanalization fails 6

Treatment Outcomes

• Successful angioplasty can result in restoration of flow without dissection and improvement in skin perfusion pressure 2
• Complete wound healing can be achieved after endovascular therapy (EVT) 2
• Technical and clinical success can be achieved with retrograde proximal anterior tibial artery access for treatment of femoropopliteal segment occlusion 6