title: Defining the Collateral Flow of Posterior Tibial Artery and Dorsalis Pedis Artery in Ischemic Foot Disease: Is It a Preventing Factor for Ischemia?
abstract: BACKGROUND
  Critical limb ischemia, a worldwide prevalent morbidity cause, is mostly secondary to vascular insufficiency due to atherosclerosis. The disease presents with intermittent claudication, which can progress to critical limb ischemia requiring amputation. Research has emphasized that the quality or existence of the pedal arch have a direct effect on wound healing and, therefore, on limb salvage, through the mechanism of collateral vascularization to the ischemic regions.
  
  
  OBJECTIVE
  This study aimed to determine the existence and, if present, grade of retrograde blood flow from plantar arch to dorsal foot artery (dorsalis pedis artery, DPA). The correlation between clinical symptoms and presence of collateral flow were also investigated.
  
  
  METHODS
  Study group consisted of 34 cases, which included patient group (n = 17, all male, mean age: 68 years) and control group (n = 17, all male, mean age: 66 years). After physical examination and lower extremity Doppler examination, spectral morphology of DPA flow was recorded, before and during manual compression of posterior tibial artery (PTA), for a period of 5 seconds. At the end, findings of Doppler ultrasound, computed tomography angiography, magnetic resonance angiography and, physical examination finding and symptomatology were gathered and analyzed.
  
  
  RESULTS
  In the patient group, 31 lower limb arteries, of total of 17 cases, were included. After compression maneuver, DPA in 11 cases (six right, five left) showed retrograde filling from plantar arch. This retrograde flow support was triphasic in three cases, biphasic in five cases, and monophasic in three cases. In other DPAs of these 20 limbs, PTA based retrograde collateral flow was not determined. In nine of these 20 limbs, with no or diminished retrograde filling, symptoms were worse than in other cases. Contrarily, only two of 11 limbs, with retrograde collaterals, have claudication during walking.
  
  
  CONCLUSIONS
  In cases with critical atherosclerotic disease of anterior tibial artery, PTA-based biphasic or triphasic retrograde collateral flow prevents ischemia, whereas monophasic support or no retrograde flow remains incapable.
authors.affiliation: Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.
authors.forename: Onur
authors.initials: O
authors.lastname: Tutar
authors.affiliation: Centermed Advanced Imaging Center, Department of Radiology, Istanbul, Turkey.
authors.forename: Duzgun
authors.initials: D
authors.lastname: Yildirim
authors.affiliation: Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.
authors.forename: Cesur
authors.initials: C
authors.lastname: Samanci
authors.affiliation: Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.
authors.forename: Babak
authors.initials: B
authors.lastname: Rafiee
authors.affiliation: Department of Cardiovascular Surgery, Kasimpasa Military Hospital, Istanbul, Turkey.
authors.forename: Kaan
authors.initials: K
authors.lastname: Inan
authors.affiliation: Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.
authors.forename: Suleyman
authors.initials: S
authors.lastname: Dikici
authors.affiliation: Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.
authors.forename: Fethi Emre
authors.initials: FE
authors.lastname: Ustabasioglu
authors.affiliation: Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.
authors.forename: Gokhan
authors.initials: G
authors.lastname: Kuyumcu
keywords: Atherosclerosis; Foot; Ischemia; Peripheral Arterial Disease; Pulsed Doppler; Ultrasonography