What revascularization options are available for a patient with an extensively calcified dorsalis pedis artery extending to the distal foot?

Revascularization Options for Extensively Calcified Dorsalis Pedis Artery

For a patient with an extensively calcified dorsalis pedis artery extending to the distal foot, endovascular revascularization should be attempted first to establish in-line blood flow to the foot, with surgical bypass to the dorsalis pedis or other pedal vessels reserved for cases where endovascular therapy fails or is technically not feasible. 1

Initial Assessment and Imaging Requirements

Before determining the revascularization approach, comprehensive vascular imaging is mandatory to evaluate all options 1:

• Digital subtraction angiography (DSA) with dedicated foot views should be obtained even in patients with extensive calcification, as non-invasive imaging (CTA, MRA, DUS) may be hampered by severe calcification in below-the-ankle arteries 1
• DSA should be performed even in patients initially deemed non-candidates for revascularization to prevent unnecessary amputation or minimize amputation extent 1
• The evaluation must be performed by an interdisciplinary care team before any amputation decision 1

Endovascular-First Strategy

Endovascular procedures are recommended as the initial approach to establish in-line blood flow to the foot 1:

• This recommendation holds even in the presence of extensive calcification, as modern techniques can often traverse heavily calcified lesions 1
• The goal is to establish direct in-line flow to at least one vessel perfusing the foot 1
• A staged approach is reasonable if disease involves multiple levels, addressing inflow disease first and outflow disease subsequently if needed 1

Factors Favoring Endovascular Approach

The following clinical scenarios strongly favor attempting endovascular revascularization first 1:

• Patient comorbidities (coronary ischemia, heart failure, severe lung disease, chronic kidney disease) that increase surgical risk 1
• Absence of suitable autogenous vein for bypass (previous vein harvest for CABG, inadequate vein diameter) 1
• Need for rapid revascularization in critical limb-threatening ischemia (CLTI) with infection or tissue loss 1

Surgical Bypass as Alternative or Salvage Option

When endovascular therapy fails or is not technically feasible, surgical bypass to the dorsalis pedis artery is a proven and durable option 1, 2, 3:

• Dorsalis pedis bypass can be performed with perioperative mortality <1% 2
• A decade-long study of 1,032 dorsalis pedis bypasses showed 5-year secondary patency of 62.7% and limb salvage of 78.2% 3
• Autogenous saphenous vein is the mandatory conduit when performing surgical bypass to pedal vessels, with significantly better outcomes than alternative conduits (67.6% vs 46.3% 5-year secondary patency) 1, 3

Factors Favoring Surgical Approach

Consider surgical revascularization when 1:

• Long-segment disease involving below-knee popliteal and/or infrapopliteal arteries in a patient with suitable single-segment autogenous vein 1
• Densely calcified lesions at the location of planned endovascular treatment that predict technical failure 1
• Small-diameter target artery proximal to the stenosis that would compromise endovascular results 1
• Single-vessel runoff distal to the ankle where durability is critical 1

Alternative Pedal Targets

If the dorsalis pedis artery itself is not suitable, other inframalleolar targets should be considered 2:

• Tarsal arteries (lateral or medial tarsal branches) 2
• Plantar arteries (medial or lateral plantar) 2
• These alternative pedal targets achieve similar limb salvage rates when dorsalis pedis is not available 2

Critical Pitfalls to Avoid

Do not proceed to amputation without attempting revascularization when technically possible, even in high-risk patients with extensive calcification 1, 4:

• Revascularization should be attempted without delay in all patients with CLTI when technically possible 1
• The screening for coronary or cerebrovascular disease should not delay management of CLTI if the patient is clinically stable 1

Do not use prosthetic conduits for pedal bypass - only two PTFE grafts in a series of 1,032 dorsalis pedis bypasses survived, both failing within one year 3

Do not assume calcification precludes revascularization - while heavily calcified vessels present technical challenges, modern endovascular techniques and surgical bypass options can still achieve limb salvage 1, 3

Post-Revascularization Management

Regardless of the revascularization method chosen 1:

• Direct flow to the foot is essential to improve healing of ulcerations 1
• Medical baseline therapy including antiplatelet agents and statins must be initiated 1
• Follow-up should include patient education, smoking cessation, protective footwear, and periodic foot care 1
• Revascularization surveillance is mandatory 1