Operative Revascularization for Trash Foot

Clinical Presentation and Diagnosis

Trash foot develops from atherosclerotic debris embolizing either spontaneously or from manipulation of a diseased proximal vessel. Depending on the clinical setting and proximal vessel characteristics, the embolic material can consist of cholesterol crystals, organized thrombus, or fibrin–platelet aggregates. This material can lodge in the major branches of the foot, including the dorsalis pedis, lateral tarsal, or plantar arteries, as well as the digital arteries. Painful bluish discoloration of the toes on one or both feet can occur initially along with livedo reticularis. With extensive embolization and a prolonged time course, ulceration and gangrene can develop. Pedal pulses may or may not be present, depending on preexisting arterial insufficiency and the site of embolic occlusion.

Prompt diagnosis is aided by strong clinical suspicion and the setting of presentation. Although not common, distal embolization to the lower extremities is a well-known complication of both open and endovascular aneurysm repair. This is thought to be caused by fragmentation of atheroma within the aorta during dissection or cross clamping during open repair or during the passage of wires and stent deployment with endovascular repair. Inadequate heparinization and in-situ thrombosis of the distal arterial circulation are other proposed mechanisms.

Digital subtraction angiography of the involved extremity with anteroposterior and lateral views of the foot can diagnose the level of proximal occlusion. Potential target pedal vessels for embolectomy or bypass can be missed owing to the limited amount of blood flow to these areas. Duplex scanning of the pedal vessels can be helpful in circumstances of occlusions starting more proximally in the tibial regions that cannot be visualized by angiography.