A BC E


DF


Figure 2. Rutherford 6 severe gangrene of the 2nd left toe wound (A) with near-infrared fluorescence angiography (NIFA, performed after intervention described earlier in article) revealing no perfusion (B), therefore 2nd toe amputation was performed. NIFA also revealed poor perfusion of the adjacent 3rd toe, however amputation was not performed due to lack of clinical symptoms or changes. Post-amputation NIFA image demonstrates adequate perfusion to the remainder of the foot. Rutherford 5 ulcer at the lateral plantar aspect of the left 1st digit (D). NIFA images obtained before (E) and after (F) selective surgical debridement of all non-viable tissue in this area, with post-debridement images demonstrating sufficient perfusion to the wound.


to the foot with filling of the deep pedal arch, but with persistent nonfilling of the pedal-plantar loop due to chronic occlusion of the left dorsalis pedis and left lateral plantar arteries (Fig. 1). Given the extent of revascularization performed, decision was made to send the patient for NIFA analysis to determine the adequacy of postrevascularization pedal perfusion prior to any more aggressive pedal- plantar loop revascularization.


Subsequent selective surgical debridement was then performed using NIFA to assess for adequate perfusion post-debridement. Left 1st hallux debridement was performed with removal of all nonviable soft tissue per NIFA (Fig. 2). The gangrenous 2nd toe was then evaluated with NIFA revealing no perfusion (Fig. 2), and therefore 2nd toe amputation was performed. NIFA also revealed nonviability of the adjacent 3rd toe; however, amputation was not performed due to lack of rest pain or gangrenous changes (Fig. 2). The patient was then discharged home with close follow-up in our multidisciplinary wound care clinic.


As demonstrated in this case, new noninvasive methods of tissue perfusion assessment demonstrate promise in the future of revascularization and wound care.


With a foundational knowledge in wound pathophysiology and of the multifactorial approach needed to fight this systemic disease, coupled with evolving endovascular techniques and perfusion analyses highlighted in this article, the interventionalist can


22 IRQ | WINTER 2019


be equipped to restore meaningful perfusion to aid limb preservation.


More online


Visit bit.ly/2RI0cXr for a companion article on practice management of wound care.


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