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Bonnetias Williams
Bonnetias Williams

Arteria Metatarsea

The possibility of avascular changes of the metatarsal heads following forefoot surgery has been previously documented. The aim of this study was to investigate the arterial supply of the lesser metatarsal heads with regard to osteotomies of these bones. We used epoxy resin injections and a modified Spalteholz technique in human cadaveric specimens to demonstrate the intraosseous and extraosseous blood supply of the lesser metatarsals. The metatarsal heads had two arterial sources: 1. The dorsal metatarsal arteries, which arose from the dorsalis pedis artery, and 2. The plantar metatarsal arteries, which are branches of the posterior tibial artery. These two vessels typically anastomosed at two sites about the metatarsal heads, forming a vascular ring and provided an extensive extraosseous arterial network around the metatarsal heads. Small arterial branches of this network run distally on the metatarsal cortex to enter the bone of the metatarsal head. The nutrient arteries traversed the cortex of the metaphysis close to the capsular and ligamentous insertions to provide multiple branches for the supply of the subchondral bone. Extensive capsular stripping during metatarsal head osteotomies results in damage to the medial and lateral head vessels.

arteria metatarsea


The first plantar metatarsal artery (arteria princeps hallucis) springs from the junction between the lateral plantar and deep plantar arteries and sends a digital branch to the medial side of the first toe.

Die Arteria metatarsea dorsalis I (EDMA) geht direkt aus der Arteria dorsalis pedis ab, die Arteriae metatarseae dorsales II-IV aus der Arteria arcuata. Die Gefäße entsenden kleine Äste nach plantar, die mit den entsprechenden Arteriae metatarseae plantares anastomosieren. Weiter distal teilen sie sich in jeweils zwei Arteriae digitales dorsales pedis.

The authors studied formation of plantar arterial arch, normal anatomy, and anatomical variations in plantar metatarsal arteries (PMTAs) regarding their origin in 50 formalinized adult cadaveric feet.

Variations in formation of plantar arterial arch as predominant lateral plantar artery supplying to most of the PMTAs were noted. Common stump of origin for the first and second, then for second and third, and also for the third and fourth PMTAs was found. In two feet, we found common stump of origin for the first PMTA and first dorsal metatarsal artery originating from deep plantar arch. Medial branch from medial plantar artery joined the first PMTA to supply the great toe deep to the transverse metatarsal ligament. In about 28% of specimens, the foot length was ranging from 21.1 cm to 22 cm and the distance between the plantar arterial arch and the posterior margin of heel was ranging between 12 and 13.5 cm. Fibular plantar marginal artery was present in all specimens.

A condition called peripheral arterial disease can reduce blood flow to your extremities. When this happens, your foot tissue may start to die. The ulcers that form from reduced blood flow are called arterial ulcers.

It is easy to palpate as part of an examination of the peripheral arterial system. Impalpable dorsalis pedis pulse is a sign of peripheral arterial insufficiency. Risk factors for peripheral arterial disease include diabetes mellitus, cigarette smoking, advancing age, hypercholesterolemia, hypertension, overweight/obesity[5] [1].

Lower extremity arterial disease (LEAD) is one of the manifestations of systemic atherosclerosis. It is associated with a high risk of cardiovascular morbidity and mortality, functional impairment, and decreased quality of life. An early diagnosis of LEAD allows a more rapid initiation of lifestyle changes and specific treatment, with a better prognosis. LEAD has the same morbidity and mortality as coronary artery disease [1]. It has similar risk factors to coronary and cerebrovascular diseases, with which it is associated in most cases [1].

When claudication occurs, patients usually seek a medical consultation, because claudication is associated with an important limitation in walking ability [5]. There are patients who may be asymptomatic for a long period of time, until advanced stages of the disease, with ischemic rest pain. In the last stage, arterial ulcers appear, that are painful and usually complicated with inflammation or infection. When the ulcer is painless, we should suspect a peripheral neuropathy, especially in diabetic patients.

Arteries are blood vessels that convey oxygen-rich blood away from the heart and supply it to different parts of the body. The dorsal metatarsal arteries are part of the arterial pathway that supplies blood to the toes.

The dorsal metatarsal arteries, as their name implies, run along the top of the metatarsal bones, which are long bones in the mid-foot that lead to the bones of the toes. These arteries often form anastomoses (connections) with the plantar metatarsal arteries, which run along the bottom of the metatarsal bones. This results in an extensive arterial network, particularly around the heads of the metatarsals.

Today, critical limb ischemia (CLI) due to diabetic arterial disease is a major worldwide cause of morbidity and mortality,1,2 affecting a large number of patients and can lead to severe disabilities. In fact, major amputations are usually associated with significant increases in mortality risk, and every effort should be pursued to minimize amputations and ensure limb salvage.3

This technique has previously been described in the literature.12-14 The access is created after specific pharmacological support to protect against spasm that compromises the puncture and wiring of the foot arteries. We usually use nitrates (0.5 mg) injected intra-arterially through the common femoral artery sheath and verapamil (5 mg/2 mL) diluted to 10 mL with saline, and 9 mL of this solution is injected intra-arterially as distal as possible, close to the foot. Local anesthesia is administered near the target area at the dorsum of the foot, and 1 mL of diluted verapamil with lidocaine is injected into the subcutaneous tissue.

Diagnostic angiography showed patency of the femoropopliteal axis and diffuse arterial disease in the BTK and BTA, with distal stenosis of the anterior tibial artery, occlusion of the posterior tibial artery, and occlusion of pedal and lateral plantar arteries (Figure 1). Due to the ulcer location, the anterior tibial artery was first approached by means of intraluminal recanalization (V14, Boston Scientific Corporation), which failed to cross the pedal artery and reach the arch. The second attempt was made with an intraluminal approach of the posterior tibial artery, which failed to recanalize the lateral plantar artery and reach the arch (Figure 2A).

Diagnostic angiography showed patency of the femoropopliteal axis, diffuse arterial disease in the BTK and BTA with occlusion of the anterior tibial artery, stenosis of the peroneal artery, distal occlusion of the posterior tibial artery, and occlusion of the plantar arteries (Figure 4). This caused very slow flow to the foot.

This extreme and advanced technical revascularization strategy, intended for challenging cases of CLI with BTK and BTA arterial disease, has been proven safe and effective for retrograde recanalization and limb salvage.8 The challenge of this approach, as previously published, remains the radiation exposition for patients and interventionists, which was significant in terms of fluoroscopy time and radiation dose.8 However, with dedicated ultrasound equipment (15- to 18-MHz hockey stick probe), this problem can be potentially mitigated or solved.

Background: The deep plantar arterial arch (DPAA) is formed by an anastomosis between the deep plantar artery and the lateral plantar artery. The potential risk of injury to the DPAA is concerning when performing transmetatarsal amputations, and care must be taken to preserve the anatomy. We sought to determine the positional anatomy of the DPAA based on anatomical landmarks that could be easily identified and palpated during transmetatarsal amputation.

The lateral plantar artery (also called external plantar artery, Latin: arteria plantaris lateralis) is one of the terminal branches of the posterior tibial artery. It supplies the sole of the foot on the lateral side.

As the largest artery distal to the ankle joint, the dorsalis pedis artery (DPA) is the chief artery of the foot (Standring et al., 2016). The DPA is the downward continuation of the anterior tibial artery (ATA) at the level of the ankle joint and courses obliquely along the dorsum of the foot to reach the 1st intermetatarsal space (Standring et al.). At this point, the DPA passes inferiorly between the two heads of the 1st interosseous muscle to complete the plantar arterial arch (Kelikian & Sarrafian, 2011; Standring et al.).

Myocutaneous flaps of the DPA have become an integral component in reconstructive surgeries of the hand, eye socket and pharyngocutaneous fistulae (Mamatha et al., 2014; Kulkarni & Ramesh). The viability of the flap is solely dependent on the degree of vascularity of this vessel (Kulkarni & Ramesh). An additional clinical implication of the DPA is the use of the DPA pulse for the assessment of peripheral arterial perfusion (Mowlavi et al., 2002; Vijayalakshmi et al.; Kulkarni & Ramesh). Presence of the DPA pulse rules out circulatory disease, whereas its absence may be indicative of occluded vessels.

Upon intricate dissection of 40 cadaveric specimens, the DPA was present in 97.5 % of cases (Table I). In 2012, Kulkarni & Ramesh found the DPA in 57.6 % of cases which is significantly lower than the result of the present study (Table II). On the other hand, the findings of Rajeshwari et al. and Kumari & Bharti were very similar to this study with an incidence of 90.48 % and 97.5 %, respectively (Table II). The absence of the DPA may result in clinical misdiagnosis as an indicator of peripheral arterial perfusion, since the absence of the DPA pulse may instead be interpreted as an occluded vessel (Kulkarni & Ramesh). Therefore, Vijayalakshmi et al. suggested confirmation by angiography before treatment is administered. 041b061a72

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