From the Guidelines
The patient with bilateral occlusions of the posterior tibial arteries and attenuated biphasic waveforms should undergo prompt evaluation and management to reduce the risk of morbidity and mortality associated with peripheral artery disease (PAD), as outlined in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1. The management of PAD involves a comprehensive approach, including lifestyle modifications and medical therapy. According to the guideline, patients with PAD should be treated with antiplatelet therapy, such as aspirin 81-325mg daily or clopidogrel 75mg daily, to reduce the risk of cardiovascular events 1. Additionally, statins, such as atorvastatin 40-80mg daily, should be prescribed to manage cholesterol levels and reduce the risk of cardiovascular disease. Some key aspects of PAD management include:
- Regular exercise, such as supervised walking programs, to improve circulation and reduce symptoms
- Blood pressure control, with a target of less than 140/90 mmHg, to reduce the risk of cardiovascular disease
- Smoking cessation, if applicable, to reduce the risk of cardiovascular disease and PAD progression
- Daily foot inspections and good foot hygiene to prevent wounds and infections
- Referral to a vascular specialist to evaluate the need for revascularization procedures, such as angioplasty, stenting, or bypass surgery, to improve blood flow and reduce symptoms. The ankle-brachial index (ABI) is a useful diagnostic tool for PAD, with a sensitivity of 69% to 79% and a specificity of 83% to 99% compared with imaging studies 1. However, in patients with diabetes or chronic kidney disease, the ABI may be falsely elevated due to noncompressible tibial arteries, and alternative diagnostic methods, such as the toe-brachial index (TBI), may be necessary 1.
From the Research
Vascular Disease and Occlusions
- The bilateral posterior tibial arteries demonstrate occlusions, which can lead to intermittent claudication and potentially progress to critical limb ischemia 2.
- The presence of occlusions in the posterior tibial arteries may require alternative access techniques, such as tibiopedal artery access, to facilitate procedural success in lower extremity arterial intervention 3.
- The quality or existence of the pedal arch has a direct effect on wound healing and limb salvage through the mechanism of collateral vascularization to the ischemic regions 4.
Treatment Options
- Antiplatelet drugs, such as aspirin, are effective in preventing cardiovascular events in patients with peripheral arterial disease (PAD), but their efficacy may vary depending on the clinical characteristics of the treated population and the type or location of atherosclerotic disease 5.
- ACE inhibitors may possess vasoactive properties that improve symptoms of claudication and are recommended for consideration in patients with PAD for cardioprotective effects 6.
- Percutaneous techniques, including thromboaspiration, thrombolysis, and correction of the underlying lesion by PTA, offer excellent early and mid-term results in selected patients presenting with acute ischemia with popliteal and/or tibial arteries occlusion 2.
Collateral Flow and Ischemia
- The existence and grade of retrograde blood flow from the plantar arch to the dorsal foot artery (dorsalis pedis artery) can prevent ischemia in cases with critical atherosclerotic disease of the anterior tibial artery 4.
- Biphasic or triphasic retrograde collateral flow may prevent ischemia, whereas monophasic support or no retrograde flow remains incapable 4.
- The presence of collateral flow can be determined through Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography 4.