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Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/semvascsurg

Review Article

Advanced limb salvage: Pedal artery interventions

Srini Tummala∗, Kenneth Briley
Department of Interventional Radiology, University of Miami Health System, UM Miller School of Medicine, 1150
NW 14th Street, Suite 702, Miami, FL 33136

a r t i c l e i n f o a b s t r a c t

Keywords: Chronic limb-threatening ischemia (CLTI) is on the rise due to the increasing prevalence of
Limb salvage diabetes, which is a significant cause of morbidity and mortality worldwide. Due to diabetes,
Pedal artery interventions many patients with CLTI present with a predominance of tibial and pedal artery disease.
Pedal loop Despite best care, limb amputation cannot always be prevented. Surgical bypass has always
CLTI been the mainstay in distal revascularization and limb salvage; however, many patients with
Peripheral artery disease, PAD CLTI have comorbidities, insufficient vein, and anatomic abnormalities that prevent them
Pedal arch from undergoing surgery. As a result, endovascular therapies have increased over the last 2
Review article decades and are providing revascularization options in these patients. Although most of the
CLI current endovascular literature has focused on above-ankle arterial interventions, recent
Pedal loop data studies have highlighted the feasibility, safety, and clinical importance of pedal artery inter-
ventions. These endovascular techniques hold promise in relieving ischemic pain, healing
foot ulcers, reducing rates and extent of amputation, and improving patient functionality
and quality of life. This review aims to comprehensively detail pedal artery interventions
in terms of anatomy, technique, intraprocedural imaging, and outcomes. In addition, sug-
gestions of when to perform pedal artery interventions and post-intervention surveillance
options will be discussed.
© 2022 Elsevier Inc. All rights reserved.

[2,3]. CLTI presents a significant burden to the patient with

1. Introduction >73% of those diagnosed progressing to amputation within
1 year [4,5]. Limb salvage is critical as primary amputation is
Chronic limb-threatening ischemia (CLTI) results in increased
associated with shorter survival and a greater risk for subse-
mortality, amputation, and poor quality of life. As defined by
quent future major amputation [5]. Although the mainstay for
the Global Vascular Guidelines, CLTI is the presence of lower
the initial management of CLTI is risk factor modification and
limb peripheral artery disease concurrently with rest pain,
medical management, many patients will progress and re-
gangrene, or ulceration of longer than 2 weeks [1]. Diabetes is
quire endovascular therapy or surgery. The choice of interven-
the most significant nontraumatic risk factor for the develop-
tion remains complex [6–8], however, immediate revascular-
ment of CLTI. As rates of metabolic disease increase through-
ization is key in preventing functional limb deficits and limb
out the developing world, so too does the need to develop
loss [6–10]. Given the prevalence of diabetes in patients with
evidence-based approaches to managing patients with CLTI
CLTI, these patients often present with more distal disease
with diffuse and severe tibial and pedal artery disease [11].
∗ When significant coexisting pedal artery disease is left un-
Corresponding author.
E-mail address: DrSriniTummala@gmail.com (S. Tummala). treated, clinical trials have demonstrated suboptimal wound

https://doi.org/10.1053/j.semvascsurg.2022.04.007
0895-7967/$ – see front matter © 2022 Elsevier Inc. All rights reserved.

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Fig. 1 – Anterior circulation of the foot. Anterior-posterior view (left image) and lateral view (right image). From Manzi M,
Cester G, Palena LM, et al. Vascular imaging of the foot: the first step toward endovascular recanalization. Radiographics
2011;31:1623–36 [22], adapted with permission.

healing and increased rates of amputation [12–17]. Such out- through fourth toes. The next branch of the DPA is the deep
comes lower patient quality of life and represent significant perforating artery, which courses medial to lateral and joins
driving forces in hospital and financial resource expenditures the posterior circulation via the lateral plantar artery [21–23].
[13,17–19]. The last decade has resulted in improved endovas- In the posterior circulation (Fig. 2), the PTA supplies the me-
cular equipment, including support catheters, guidewires, dial ankle and the plantar surface of the foot. The PTA gives
and angioplasty balloons. In addition, advanced endovascular rise to the common plantar artery and the medial calcaneal
techniques and devices have improved. These factors have re- artery. The common plantar artery bifurcates at the calcaneal
sulted in improved outcomes of previously unreconstructable body into the medial and lateral plantar arteries with the lat-
pedal artery disease [20]. Consequently, there has been a re- eral plantar artery forming an anastomosis with the deep per-
newed interest in pedal artery interventions. In this review, forating artery forming the plantar arch of the foot.
we discuss the many facets of pedal artery interventions, in- As a result of this complex anatomy, three anastomotic
cluding anatomy, technique, optimal intraprocedural imaging, loops are often described and are useful when considering
outcomes, suggestions of when to perform pedal artery inter- pedal artery interventions. The most common is the pedal
ventions, and post-intervention surveillance. plantar loop formed by the DPA, deep perforating artery, lat-
eral plantar artery, and PTA (Fig. 3). This loop is also referred
to as the “pedal arch” or the “pedal loop” and is most com-
2. Anatomy monly referred to when discussing endovascular pedal loop
interventions. This loop is complete in approximately 90% of
The arterial supply to the foot is composed of anterior and cases, which is advantageous when performing pedal plantar
posterior circulatory pathways. These anterior and posterior loop reconstructions. Another loop in the foot called the “deep
pathways are supplied predominantly by the anterior tibial pedal arch” is a more proximal communication between the
(ATA) and posterior tibial (PTA) arteries, respectively. Although superficial branch of the medial plantar artery and the me-
the peroneal artery supplies both territories of the foot, espe- dial tarsal artery (Fig. 4). Although this loop is typically nar-
cially in the setting of ATA and PTA occlusive disease, in gen- row and difficult to navigate with guidewires, catheters, and
eral it is not a significant artery when discussing pedal artery balloons, it may become the dominant connection in patients
interventions. In the anterior circulation (Fig. 1), the ATA be- after forefoot amputations or occlusion of the pedal plantar
comes the dorsalis pedis artery (DPA) at the ankle joint, which loop. Finally, a loop formed by an anastomosis of the arcuate
then travels distally and supplies the dorsum of the foot. The artery with the lateral tarsal artery is only seen in a small per-
DPA gives rise to a number of branches, including the medial centage of patients [21–23].
and lateral malleolar arteries, medial and lateral tarsal arter- Of course, pedal artery variations exist and are common.
ies, and the arcuate artery and deep perforating artery, both at These anatomic variants are well described and make pedal
the first metatarsal space. The arcuate artery, when present, artery interventions in patients with CLTI challenging, es-
forms an anastomotic loop with the lateral tarsal artery and pecially in the setting of significant occlusive disease when
gives rise to the small dorsal digital arteries of the second anatomy is difficult to determine [22].

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Fig. 2 – Posterior circulation of the foot. Lateral view (left image) and anterior-posterior view (right image). From Manzi M,
Cester G, Palena LM, et al. Vascular imaging of the foot: the first step toward endovascular recanalization. Radiographics
2011;31:1623–36 [22], adapted with permission.

Fig. 3 – Lateral oblique view (left image) and anterior-posterior view (right image) show the pedal-plantar loop. The dorsalis
pedis artery (arrows) is connected via the deep perforating artery (∗ ) in the first metatarsal space with the plantar arch and
lateral plantar artery (arrowheads). From Manzi M, Cester G, Palena LM, et al. Vascular imaging of the foot: the first step
toward endovascular recanalization. Radiographics 2011;31:1623–36 [22], adapted with permission.

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 S e m i n a r s i n Va s c u l a r S u r g e ry 3 5 ( 2 0 2 2 ) 2 0 0 – 2 0 9 203

Fig. 4 – The deep pedal arch is a proximal communication between the superficial branch of the medial plantar artery and
the medial tarsal artery. From Manzi M, Cester G, Palena LM, et al. Vascular imaging of the foot: the first step toward
endovascular recanalization. Radiographics 2011;31:1623–36 [22], adapted with permission.

femoral access is unattainable. In this case, retrograde con-

3. Technique tralateral femoral access is achieved and may be used as well
[22]. However, sheath position as distal as possible in the P2
Over the last decade, there have been improvements in en-
or P3 segment of the popliteal artery is still recommended for
dovascular equipment, which are used during pedal artery
the reasons described above.
interventions. These include improved 0.014-inch support
catheters, guidewires, and low-profile angioplasty balloons.
In addition, advanced endovascular techniques, such as ret- 4. Intraprocedural imaging
rograde pedal and digital artery access, controlled antegrade
and retrograde subintimal tracking, reverse controlled ante- Once optimal access is achieved, imaging is important to the
grade and retrograde subintimal tracking, and subintimal ar- success of any pedal artery intervention. Digital subtraction
terial flossing with antegrade-retrograde intervention have angiography including antero-posterior and lateral oblique
been perfected [20,24–29]. views of the foot are essential. Manzi et al. [22] established
In general, pedal artery interventions are best performed general criteria for optimal positioning and evaluation of the
using antegrade access into the common femoral or proximal pedal arteries. The antero-posterior view (Fig. 5) should in-
superficial femoral artery. Once access is obtained with ultra- clude the proximal first metatarsal interspace and forefoot in
sound guidance, a 6Fr vascular sheath is introduced as distal order to show the pedal-plantar loop passing from the dor-
as possible, typically in the P2 or P3 segment of the popliteal sal portion to the plantar portion, as well as the origins of
artery [30]. A 6Fr sheath optimizes imaging and allows the use the tarsal and metatarsal arteries. It is also important that
of two 0.014-inch guidewires, catheters, and balloon systems, the lateral oblique view (Fig. 6) project the fifth metatarsal
if needed. In addition, the distal position of the sheath opti- bone outward from the base of the foot and include the heel
mizes visualization of chronic total occlusion cap morphology, and proximal forefoot. This projection allows optimal imag-
collaterals, and reconstitution points. Antegrade access also ing of the common planter artery bifurcation into the medial
allows for more pushability, torqueability, and a shorter dis- and lateral plantar arteries and optimizes visualization of the
tance to travel to treat disease below the ankle. Ergonomics is DPA and the pedal plantar loop [22]. This initial evaluation is
improved and radiation exposure to the operator’s arms and of paramount importance to visualize chronic total occlusion
hands is also reduced significantly, regardless of which leg is caps, collateral flow, variant anatomy, determine the need for
being treated. There are times when safe ipsilateral antegrade alternative access sites, and helps to plan a treatment strategy.

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Fig. 5 – Anterior-posterior view should include the proximal first metatarsal interspace and forefoot (left image) in order to
show the pedal-plantar loop passing from the dorsal portion to the plantar portion (arrowhead). From Manzi M, Cester G,
Palena LM, et al. Vascular imaging of the foot: the first step toward endovascular recanalization. Radiographics
2011;31:1623–36 [22], adapted with permission.

Fig. 6 – Lateral oblique view (left image) should project the fifth metatarsal bone outward from the base of the foot and
include the heel and proximal forefoot. This projection (right image) allows optimal imaging of the common planter artery
bifurcation into the medial and lateral plantar arteries and optimizes visualization of the dorsalis pedis artery and the pedal
plantar loop. From Manzi M, Cester G, Palena LM, et al. Vascular imaging of the foot: the first step toward endovascular
recanalization. Radiographics 2011;31:1623–36 [22], adapted with permission.

Despite optimal technique and imaging and a well- the first metatarsal artery is accessed in retrograde fashion.
formulated treatment plan, there is still a >20% failure rate In addition, a myriad of well-described chronic total occlu-
using access from above only. As a result, other alternative ac- sion crossing and pedal plantar loop techniques and newer
cess sites are often needed, including direct antegrade access endovascular devices increases the odds of treatment suc-
into the ATA, PTA, DPA, and/or retrograde access into the lat- cess. When the above are combined, successful intervention
eral plantar and common planter arteries. In some instances, is achieved in up to 85% of cases [20,29,31,32].

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 S e m i n a r s i n Va s c u l a r S u r g e ry 3 5 ( 2 0 2 2 ) 2 0 0 – 2 0 9 205

Fig. 7 – Patient status post–second toe resection for nonhealing ulcer and associated osteomyelitis with development of
gangrene at the operative site (a). Preintervention angiogram (b) shows incomplete pedal loop and suboptimal digital flow.
After successful pedal artery intervention (c), robust intraoperative bleeding was seen during surgery (d) with subsequent
complete healing (e).

plasty (PAA) (n = 140) and those who did not (n = 117). Patients
5. Pedal artery intervention data (feasibility, were also classified into low risk, moderate risk, and high risk
safety, and outcomes) on the basis of a delayed wound healing score that was deter-
mined by a number of independent predictors described in the
In 2009, Manzi and his colleagues [20] first described the pedal- study. In the low-risk population, those who underwent PAA
plantar loop technique. In their prospective trial of more than had increased rates of wound healing compared with those
1,300 patients with CLTI (10.1% were pedal artery interven- who did not (93.3% v 69.2%; P = .184), but the result was not sta-
tions), pedal artery interventions were safe and technically tistically significant. In the moderate-risk population, the PAA
feasible in 85% of cases and provided positive clinical results group had a significantly higher rate of wound healing (59.3%
at 12 months. v 33.9%; P = .001) and shortened healing times (211 v 365 days;
Later, Kawarada and his colleagues [12] were the first to P = .008). However, in the high-risk population, additional PAA
describe a practical pedal arch classification system and also did not demonstrate efficacy (29.4% v 35.7%; P = .477) [33]. A
showed that pedal arch status was an independent predic- subset analysis also showed that the wound healing rate was
tor of wound healing. At that time, his team suggested that improved at 1 year, irrespective of the degree of pedal artery
revascularization to establish a pedal arch was vital to facili- disease [34]. Further studies have built on the importance of
tate complete wound healing. an intact pedal arch on wound healing, limb salvage, minor
A few years later, the RENDEZVOUS trial found a direct amputation-free survival, and overall survival in patients with
correlation between rate and extent of wound healing after CLTI.
pedal artery intervention [33,34]. In this multicenter prospec- The single-center retrospective study by Troisi et al.
tive study including 5 Japanese institutions, 257 patients with [36] subdivided 137 patient with CLTI with nonhealing foot
CLTI with infrapopliteal and pedal artery disease were di- ulcers after endovascular therapy into three groups based on
vided into two cohorts: those receiving pedal artery angio- pedal arch status: complete pedal arch (CPA, n = 42 [30.7%]), in-

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Fig. 8 – Large area of nonhealing ulceration in the foot (a). Preintervention angiogram shows severe tibial and pedal artery
disease (b). After tibial intervention and pedal artery intervention (c), final angiography showed in-line flow in the anterior
tibial and dorsalis pedis arteries, patent pedal plantar loop, robust filling of the posterior tibial artery via collaterals, and an
angiographic wound blush (d), which resulted in significant healing (e).

complete pedal arch (IPA, n = 60 [43.8%]), and an absent pedal CLTI. Their analysis evaluated the safety and effectiveness of
arch (APA, n = 35 [25.5%]). The CPA cohort demonstrated a PAA and assessed whether additional PAA after tibial artery
higher rate of wound healing (50%) compared with the IPA and intervention would improve clinical outcomes. This review
APA cohorts (28.3% and 20%, respectively; P = .01), improved included 10 articles, 478 patients, and 524 legs treated with
1-year limb salvage rates (100% v 93.8% and 70.1%), improved PAA. The pooled 1-year limb salvage and amputation-free sur-
1-year minor amputation-free rates (84.1% v 82.4% and 48.9%; vival rates were 92% and 78%, respectively. Although there was
P = .001), and improved overall survival rates (90% v 80.8% and no statistically significant difference when tibial plus pedal
62.7%; P < .001) [36]. artery angioplasty was compared with tibial artery interven-
In a similarly designed and parallel study, Ismail and tion alone, the wound healing rates were better in patients
Ahmed [37] studied a cohort of 60 consecutive diabetic pa- who had both tibial and pedal artery disease treated success-
tients with CLTI with CPA (n = 15 [25%]), IPA (n = 26 [43.3%]), fully [38].
or APA (n = 19 [31.7%]). Their study identified increased rates An additional retrospective analysis by Jung and colleagues
of limb salvage (CPA 100% v IPA 88.5% v APA 68.4%; P = .01) [39] demonstrated that patients undergoing successful pedal
and healing time (CPA 3.4 months v IPA 4 months v APA 6.1 artery intervention had higher rates of wound healing (76%
months; P = .02) in those patients who had a CPA compared v 67%; P = .031) and a lower major amputation rate (96.3% v
with those who did not [37]. 84.2%; P = .009) at 1 year compared with those who did not.
Around the same time, Huizing et al. [38] performed a sys- Major adverse limb events, freedom from reintervention, and
tematic review and meta-analysis of PAA in patients with overall survival were not significantly different between those

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 S e m i n a r s i n Va s c u l a r S u r g e ry 3 5 ( 2 0 2 2 ) 2 0 0 – 2 0 9 207

Fig. 9 – Diabetic patient with wound dehiscence and infection at left fifth toe amputation site (a). Despite successful pedal
artery intervention with intact pedal plantar loop (b), there was no healing at the amputation site due to diabetic
microcirculation disruption (red circles) (c). However, pedal artery intervention allowed healing of a transmetatarsal
amputation (d).

who underwent a successful pedal artery intervention and and pedal artery disease if optimal healing does not occur
those who did not [39]. after successful tibial artery intervention, patients with gan-
grene/tissue loss (Figs. 7 and 8), and those with post-surgical
ischemic wounds from forefoot amputations, as surgery may
6. Pedal artery interventions in practice separate the anterior and posterior circulations of the foot
(Fig. 9). In these patients, direct in-line flow based on an-
Although the feasibility and safety of pedal artery interven- giosome and angiographosome revascularization can opti-
tions has been demonstrated and the positive impact of pedal mize blood flow to the ischemic wound or surgical flap
artery interventions has been shown, there are still limited [20,23,35,38,41–46].
data and a lack of widespread adoption. This is due to the
lack of randomized controlled trials (RCTs), lack of societal
guidelines of when to intervene and the extent of reconstruc-
tion needed, and the lack of expertise by many vascular spe- 7. Post-intervention surveillance
cialists today. More RCT data may lead to incorporation of
these interventions into societal guidelines. This would then After a successful pedal artery intervention, surveillance is an
allow vascular training programs to incorporate these tech- important part of patient management. To ensure a successful
niques and therapies more robustly into their training pro- outcome, timing based on the patient’s comorbidities, overall
grams, thus increasing the numbers of experts in this type of clinical scenario, and risks of limb amputation if the treated
complex intervention. As with any CLTI treatment, the goal of arteries close prematurely must be considered. However, as-
pedal artery interventions is to relieve ischemic pain, heal ul- sessment of the pedal arteries and determination of foot per-
cers, prevent limb loss, improve patient function and quality fusion is challenging due to limited techniques and published
of life, and prolong survival [40]. In general, pedal artery inter- data in this vascular territory. Commonly, ankle-brachial in-
ventions should only be performed in the setting of CLTI and dex (ABI), toe-brachial index (TBI), duplex ultrasound, tran-
limb salvage. Patients who are nonambulatory, wheelchair scutaneous oxygen pressure, and toe photoplethysmography
bound, or have no hope for functional recovery of their limb are used for noninvasive testing. Although these are excellent
despite revascularization should not undergo pedal artery studies, there are limitations. Specifically, most patients with
intervention. CLTI have diabetes or chronic kidney disease, which often re-
Currently, non-RCT data and expert opinion support com- sults in erroneous ABI and TBI measurements. In addition,
mon scenarios in which pedal artery interventions may be small-diameter vessels, vessel tortuosity, calcification, bone-
necessary. These include patients with CLTI with both tibial related artifacts, and prior amputations limit assessment of

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208 S e m i n a r s i n Va s c u l a r S u r g e ry 3 5 ( 2 0 2 2 ) 2 0 0 – 2 0 9

the pedal arteries using duplex ultrasound, transcutaneous [7] Bisdas T, Borowski M, Stavroulakis K, et al. Endovascular ther-
oxygen pressure, and toe photoplethysmography. apy versus bypass surgery as first-line treatment strategies for
Recently, a new technique to determine foot perfusion in critical limb ischemia: results of the interim analysis of the
CRITISCH Registry. JACC Cardiovasc Interv 2016;9:2557–65.
patients with CLTI called pedal acceleration time has been
[8] Siracuse JJ, Menard MT, Eslami MH, et al. Comparison of
described. This technique uses duplex ultrasound to directly
open and endovascular treatment of patients with critical
visualize the pedal arch, map the pedal artery anatomy, and limb ischemia in the Vascular Quality Initiative. J Vasc Surg
determine pedal flow hemodynamics. It is an objective mea- 2016;63:958–65.
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been shown to correlate with ABI/TBI measurements and pre- AHA/ACC guideline on the management of patients with
dict wound healing [47–49]. Clearly, more study and data are lower extremity peripheral artery disease: a report of the
American College of Cardiology/American Heart Association
needed, but this technique is showing promise in patients
Task Force on Clinical Practice Guidelines. J Am Coll Cardiol
with CLTI. 2017;69:e71–126.
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with lower extremity peripheral artery disease: executive
8. Conclusions summary: a report of the American College of Cardiol-
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The benefits of pedal artery interventions are becoming Practice Guidelines. Circulation 2017;135(12):e686–725.
clearer. Although non-RCT data and expert opinion are help- [11] Beckman JA, Schneider PA, Conte MS. Advances in revascular-
ization for peripheral artery disease: revascularization in PAD.
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Circ Res 2021;128:1885–912.
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Declaration of Competing Interest
hemodialysis. Eur J Vasc Endovasc Surg 2015;49:565–73.
[14] Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consen-
Srini Tummala is a course faculty, speaker, and consultant for sus for the Management of Peripheral Arterial Disease (TASC
Abbott Vascular, Cardiovascular Systems Inc, and Terumo. The II). J Vasc Surg 2007;45(suppl S):S5–67.
remaining author discloses no conflicts. [15] Graziani L, Silvestro A, Berton A, et al. Vascular involvement in
diabetic subjects with ischemic foot ulcer: a new morphologic
categorization of disease severity. Eur J Vasc Endovasc Surg
2007;33:453–60.
[16] Chung J. Endovascular devices and revascularization tech-
Supplementary materials
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Supplementary material associated with this article can be [17] Romiti M, Albers M, Brochado-Neto FC, et al. Meta-analysis of
found, in the online version, at doi:10.1053/j.semvascsurg. infrapopliteal angioplasty for chronic critical limb ischemia. J
2022.04.007. Vasc Surg 2008;47:975–81.
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