case_images: PMC10566265_01
case_images: Digital image showing an extensive necrotic lesion on the dorsum of the left foot after a previous episode of bullous erysipelas.
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case_images: A 78-year-old man presented with an extensive necrotic lesion on the dorsum of the left foot after an episode of bullous erysipelas 2 months earlier (Figure 1).
case_images: Digital subtraction angiogram. (a) The left common and superficial femoral arteries exhibited diffuse atherosclerotic disease without significant stenosis. (b) The left popliteal artery presented an aneurysm in its upper third (black arrow). (c) This artery occluded below the knee joint, just next to the tibio-peroneal trunk emergence (white arrow). Both anterior tibial and posterior tibial arteries were not contrasted. Enlarged genicular arteries were observed as collaterals and filled the peroneal artery in the mid-leg (black arrowhead). (d) The peroneal artery (black arrowhead) was the single runoff vessel to the ankle. (e) In the ankle, the dorsalis pedis (white asterisk) and the posterior tibial (white arrowhead) arteries were contrasted and formed an incomplete pedal arch.
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case_images: Enlarged genicular arteries were observed as collaterals and filled the peroneal artery in the mid-leg, the single runoff vessel that reconstituted the pedal arch (Figure 2).
case_images: Intraoperative digital images. (a) Medial thigh access view:the proximal anastomosis (black arrow) was made in the distal superficial femoral artery (white arrow). (b) Medial leg access view:the distal anastomosis was done in the peroneal artery (white arrowhead) with a vein cuff (black arrowhead) using the "Brighton sock" technique.
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case_images: The "free end" of the vein was longitudinally incised and sewn to the distal end of the PTFE graft (Figure 3).
case_images: Schematic diagram of the procedure. A femoro-peroneal bypass was done using a tapered reinforced expanded polytetrafluoroethylene (PTFE) graft and a vein cuff in the distal anastomosis. The proximal anastomosis was made in the distal superficial femoral artery, just proximal to the aneurysm, which was treated with a proximal and distal ligation. The distal anastomosis was done in the peroneal artery with a vein cuff, using the "Brighton sock" technique. A short segment of the proximal ipsilateral great saphenous vein was harvested and submitted to saline distension. Macroscopic inspection allowed us to choose a healthy venous piece of adequate diameter. The vein was spatulated at one end and was anastomosed to the peroneal artery in a standard fashion. The "free end" of the vein was longitudinally incised and sewn to the distal end of the PTFE graft.
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case_images: Figure 4 summarizes what was done.
case_images: Completion angiogram. (a) The proximal anastomosis (black arrow) provided a good inflow, and the popliteal aneurysm was excluded. (b) The distal anastomosis (white arrow) had an excellent outflow to the peroneal artery.
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case_images: The distal anastomosis had an excellent outflow to the peroneal artery with a fast flow to the pedal vessels (Figure 5).
case_images: Follow-up digital images. A partial skin graft harvested from the ipsilateral thigh was used to cover the wound, which presented complete healing in 2 months.
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case_images: Two weeks after debridement, a partial skin graft harvested from the ipsilateral thigh was used to cover the wound, which showed complete healing in 2 months (Figure 6).