Infrapopliteal (IP) peripheral arterial disease (PAD) often occurs as part of multilevel atherosclerotic disease and is more commonly seen in patients with long-standing diabetes mellitus, patients with chronic kidney disease, or the elderly.¹ Presence of moderate stenosis with 1 or 2 critical lesions can disrupt pulsatile flow to the limb. Chronic stable limb ischemia is predominantly asymptomatic, with a minority (20%) of patients complaining of symptoms of claudication. Rest pain and/or tissue necrosis occurs (Figure 36-1) when the compensatory mechanisms that were developed in absence of straight line flow, such as ischemic preconditioning of the limb and development of the collaterals, are no longer capable to meeting the oxygen demands.² The arterial tree below the knee has relatively smaller-caliber vessels that in this population are often calcified, and stenotic lesions are rather diffuse (Figure 36-2).

Open vascular repair has been the mainstay of treatment, but given the significant comorbidities and lack of viable distal bypass target, endovascular approach is typically considered first. Patients who do have a patent artery that provides direct flow to the foot without other major comorbid conditions and have good vein conduit for bypass should be considered for surgical bypass. Patients with limited life expectancy and extensive gangrene or necrosis should undergo primary amputation.

Patients with IP disease in conjunction with femoral-popliteal disease have a lower risk for amputation and have longer amputation-free survival when compared with patients who have IP disease only.³ Patients who will benefit from revascularization include patients with Rutherford categories 4 to 6, systolic ankle pressure <50 mm Hg, nonpulsatile plethysmographic tracing, and/or transcutaneous oxygen pressure <30 mm Hg.^4,5 Clinically, patients present with limb pain at rest, nonhealing ischemic ulceration, or gangrene. The pain is usually located in the acral portion of the leg, toes, or heels and is severe and persistent. The feet may be insensitive to cold, joints may be stiff, and patients may suffer from hyperesthesia. Patients may complain of pain relief when feet are in dependent position, and conversely, pain may increase if feet are above the level of heart or even when laying in bed with feet at heart level. Patients will often narrate how they have pain in the feet at night that gets better when they hang the feet over the side of the bed. During a clinic visit, one may be deceived by rubor that is ­typically present when patients remove their shoes, but it is important to stress that this “dependent rubor” (Figure 36-3) is matched by “elevation pallor” (Buerger sign) (Figure 36-4). Sometimes, the initial presentation will be gangrene or a wound, as is the case in ­people with advanced diabetes mellitus and associated ­neuropathy. It is important to know that this particular patient subset may not have rest pain due to neuropathy. Incorporation of handheld Doppler in the clinic can help the clinician to estimate presence of blood flow at various levels in the foot. Doppler signals from ­dorsalis pedis can be picked up at the level of ankle crease (Figure 36-5), and one could follow the course of the dorsalis pedis right to the deep plantar artery that lies between the first and second metatarsal bone (Figure 36-6). Similarly, the peroneal trunk can be heard in the ankle area (Figure 36-7) and can be followed into plantar arteries at least in the proximal area. In “thinner” legs, Doppler signals from the anterior tibial artery can also be picked up along the lateral border of the tibial boney prominence (Figure 36-8).

A thorough knowledge of the arterial tree and its surface projections below the knee including the foot is of paramount importance for possible revascularization. The popliteal artery courses along the posterior surface of the femur and tibia. It divides into 2 branches just below the proximal anastomosis of the fibula to the tibia, giving rise to an anterior tibial artery and a tibial peroneal trunk (Figure 36-9). The anterior tibial artery pierces the interosseus membrane between the tibia and the fibula and courses along the anterior surface of the interosseus membrane close to the tibia, where it changes at the ankle joint and becomes the dorsalis pedis artery (Figure 36-10). Lateral and medial malleolar branches can form interconnections between the anterior and posterior tibial arteries and the peroneal artery as a form of collateral circulation when there is a stenotic lesion. The dorsalis pedis terminates as the deep plantar artery, which enters the sole of the foot to join the lateral plantar artery to form the plantar arch (passes between 2 heads of first dorsal interosseous muscle) (Figure 36-11).