Anatomical Variations for Infrapopliteal Intervention

A 64-year-old lady with history of coronary artery bypass surgery and diabetic foot ulcer referred for revascularization of the below the knee arteries. Diagnostic angiography by the ipsilateral approach showed total occlusion before dorsalis pedis artery. We decided to attempt recanalization of CTO in the distal ATA artery to the dorsalis artery to establish ‘‘one straight-line flow’’ to the foot. A 6-F guide catheter was placed to the right popliteal artery through a 6-F antegrade sheath via the right common femoral artery. Crossing of the occlusive lesion from ATA to dorsalis pedis with a 0.014-inch guide wire (Regalia and halberd) supported by a 2 mm long over-the-wire balloon was unsuccessful. Careful reviewing of images revealed probable continuation of Peroneal artery to dorsalis pedis as Type IIIb anatomic variation. Wiring was made along the Peroneal artery tract to the occluded segment into dorsalis pedis artery, followed by balloon dilatation. The totally occlusive lesion was completely recanalized without any significant dissection and residual stenosis. Final angiography showed an excellent result, indicating a Type IIIb variant.