case_images: PMC11255652_01
case_images: Angiography of an iatrogenic arteriovenous fistula in first to third sessions of endovascular therapy, and delayed wound healing in the right foot. (A) Gangrene in the second toe. (B) Initial and final angiography in the first session procedure (white arrow = distal puncture point of the distal posterior tibial artery; white and yellow arrowheads = iatrogenic arteriovenous fistula). (C) Final angiographic image after revascularisation of the anterior tibial artery in the second session procedure (yellow arrowhead = arteriovenous fistula). (D) Delayed wound healing in the second toe and a new wound in the fifth toe and heel. (E) Final angiogram after revascularisation of the posterior tibial artery in the third session procedure (yellow arrowhead = severe steal phenomenon through the arteriovenous fistula).
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case_images: However, she developed gangrene of the second toe of her right foot one month earlier and was diagnosed with recurrent CLTI (Fig. 1A). An initial angiogram demonstrated in stent occlusion in the SFA, and the distal posterior tibial artery (PTA) to the plantar artery appeared as an infra-malleolar vessel runoff (Fig. 1B). A 2 mm balloon was dilated in the popliteal artery and PTA; however, angiography showed an AVF in the proximal and distal PTA (Fig. 1B). However, the dorsalis pedis artery was absent, and the antegrade blood flow was stolen via the AVF at the distal PTA (Fig. 1C). However, new wounds appeared on the heel and fifth toe (Fig. 1D). Nevertheless, severe steal syndrome due to the AVF at the distal PTA persisted despite prolonged balloon inflation (Fig. 1E).
case_images: Preliminary physiological assessment of peripheral perfusion via laser Doppler flowmetry. (A) Severe steal phenomenon through the arteriovenous fistula on the initial angiogram. (B) Simulated closure of the arteriovenous fistula using a guiding extension catheter (asterisk indicates the guiding extension catheter). (C) Laser Doppler flowmetry probes attached to the skin on the dorsal, heel, first toe, and fifth toe areas of the foot. Measurements of LDF in the fifth toe increased remarkably after simulated closure of the arteriovenous fistula.
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case_images: AVF in this case. A significant increase in blood flow was observed in the heel, especially the fifth toe, which is the plantar artery perfusion area (Fig. 2A-C).
case_images: Final angiogram after implanting a covered stent and changes in peripheral perfusion according to laser Doppler flowmetry during the procedure. (A) Final angiogram showing complete closure of the arteriovenous fistula and direct flow to the forefoot. (B) Changes in laser Doppler flowmetry measurements during the procedure. Peripheral perfusion using laser Doppler flowmetry gradually increased in the heel and fifth toes during coiling and covered stent implantation.
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case_images: F guiding catheter was inserted retrogradely via the distal PTA, and two major vein branches were embolised using coils; however, the veins were so markedly branched that it was difficult to achieve complete closure. Finally, a covered stent was implanted in the PTA, achieving complete AVF closure (Fig. 3A). Laser Doppler flowmetry measurements gradually increased in the heel and fifth toe during coiling and covered stent implantation (Fig. 3B).