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  • Severe pain of the forefoot that is relieved by dependency (ischemic rest pain).

  • Pain or numbness of the foot with walking.

  • Ulcer or gangrene, and not claudication, is a frequent initial manifestation.

  • Pallor when the foot is elevated.


Occlusive processes of the tibial arteries of the lower leg and pedal arteries in the foot occur primarily in patients with diabetes (eFigure 12–3). There often is extensive calcification of the artery wall. While claudication is a common initial symptom of ischemia, it may not be present.

eFigure 12–3.

Common sites of stenosis and occlusion of the visceral and peripheral arterial systems. (Reproduced, with permission, from Way LW [editor]. Current Surgical Diagnosis & Treatment, 10th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)


A. Symptoms and Signs

Unless there are concomitant lesions in the aortoiliac or femoral/superficial femoral artery segments, the first manifestation of leg ischemia due to tibial artery disease is frequently an ischemic ulcer or foot gangrene, rather than claudication. The presence of ischemic rest pain or ulcers is termed chronic limb-threatening ischemia and is associated with the highest rate of amputation. Classically, ischemic rest pain is confined to the dorsum of the foot and is relieved with dependency: the pain does not occur with standing, sitting, or dangling the leg over the edge of the bed. It is severe and burning in character, and because it is present only when recumbent, it may awaken the patient from sleep.

On examination, femoral and popliteal pulses may or may not be present depending on disease extent, but palpable pedal pulses will be absent. Dependent rubor may be prominent with pallor on elevation. The skin of the foot is generally cool, atrophic, and hairless.

B. Doppler and Vascular Findings

The ABI is often below 0.4; however, the ABI may be falsely elevated due to calcification of the arterial media layer (Mönckeberg medial calcific sclerosis) and may not be compressible. Toe-brachial indexes are preferred for assessing perfusion and predicting wound healing.

C. Imaging

Digital subtraction angiography is the gold standard method to delineate the anatomy of the tibial-popliteal segment (eFigure 12–4). MRA or CTA is less helpful for detection of lesions in this location due to the small vasculature and other technical issues related to image resolution.

eFigure 12–4.

Magnetic resonance angiography of the arteries below the knee. Only the peroneal arteries are patent, which is the typical pattern in diabetic patients with atherosclerosis.


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