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ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 380-384

Unusual anatomical variations in plantar metatarsal arteries and plantar arterial arch with surgical significance


1 Assistant Professor, Department of Anatomy, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune, Maharashtra, India
2 Director Academics, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune, Maharashtra, India

Date of Submission20-Jul-2020
Date of Acceptance03-Aug-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Preeti Shivshankar Awari
Assistant Professor, Department of Anatomy, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth (Deemed to be University), Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_101_20

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  Abstract 


Background: Critical limb ischemia (CLI) has been a burden on society where revascularization of arteries is the first line of treatment. If the antegrade approach is not possible, retrograde approach through pedal–plantar loop can be done, resulting in better prognosis. For the same reason, assessment of blood vessels of foot in general is practiced before any intervention. Having information about normal anatomy and anatomical variants of these blood vessels could be of great help to the interventionist to reduce the postoperative complications. Context: 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. Results and Conclusion: 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. Implications: In the retrograde approach for the revascularization in cases with CLI, most of the surgeons are trying the approach through plantar pedal loop or direct puncture of metatarsal arteries. Data collected on plantar metatarsal normal anatomy and anatomical variations can be kept in mind while doing any intervention with better prognosis.

Keywords: Below-ankle approach, below-knee approach, critical limb ischemia, medial plantar artery, metatarsal artery puncture, pedal–plantar loop, plantar metatarsal arteries, revascularization


How to cite this article:
Awari PS, Vatsalaswamy P. Unusual anatomical variations in plantar metatarsal arteries and plantar arterial arch with surgical significance. Indian J Vasc Endovasc Surg 2020;7:380-4

How to cite this URL:
Awari PS, Vatsalaswamy P. Unusual anatomical variations in plantar metatarsal arteries and plantar arterial arch with surgical significance. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Jan 16];7:380-4. Available from: https://www.indjvascsurg.org/text.asp?2020/7/4/380/304621




  Introduction Top


Peripheral arterial disease (PAD) is a huge burden on the society. Almost 200 million adults are suffering from PAD worldwide.[1] In that also, critical limb ischemia (CLI) is the most severe pattern of peripheral artery disease.[2]

Revascularization of lower-limb arteries (above knee or below knee or below ankle depending on the location of occlusion) is the first-line treatment in CLI patients to improve the condition of the patient, wound healing, and prevent amputation.[3] There are many articles which state about failure of conventional antegrade revascularization for occlusive lesions which ranges from 10% to 40% in the below-knee intervention, even with the use of newer techniques and devices.[4],[5],[6]

Manzi et al. have tried both antegrade and retrograde approaches and the use of pedal–plantar loop technique in case of tibioperoneal occlusion with better prognosis.[7],[8] Fusaro et al. had mentioned that if endovascular intervention with an antegrade approach through a distal tibial vessel is impossible, then retrograde approach may be technically feasible through the pedal–plantar loop.[9] In 2012, Palena and Manzi did retrograde the direct puncture of the transmetatarsal arteries or the plantar arch with better prognosis in almost 71% of patients.[10] Davidson and Callis reported better prognosis in 75 bypasses to the arteries of the foot and ankle in patients with CLI with occluded below the knee vessels and a patent pedal arch.[11]

Nowadays, before any surgical intervention including distal bypass grafting, evaluation of pedal arch is recommended in cases with CLI as it is associated with improved wound healing after revascularization.[12],[13],[14],[15],[16],[17] Pedal arch status seemed to be a positive prognostic marker for limb salvage and survival in diabetic patients with CLI.[18] Yamada et al. state that thorough knowledge of the arterial supply of the foot is of great importance in vascular reconstruction.[19]

This review of literature regarding recent advancements in noninvasive vascular interventions as retrograde transmetatarsal artery puncture and pedal–plantar loop intervention for critical limb ischemia boosted the authors to study the normal anatomy and anatomical variations in the plantar arterial arch and plantar metatarsal arteries (PMTAs). Normal anatomy of plantar arterial arch and PMTAs is described in many anatomy books. The lateral plantar artery after originating from the posterior tibial artery passes distally and laterally to the fifth metatarsal base where it turns medially to reach the interval between the first and second metatarsal bases and unites with the deep plantar artery, a branch of dorsalis pedis artery to complete the plantar arch.[20] This arch gives rise to four PMTAs.[21] A lateral digital branch to the fifth toe originates from the lateral plantar artery near the fifth metatarsal base. This artery is given the name fibular plantar marginal artery.[22]


  Materials and Methods Top


Fifty formalinized adult cadaveric feet from Dr. D Y Patil Medical College, Hospital and Research Centre, Dr. D Y Patil Vidyapeeth (Deemed to be University), Pune, Maharashtra, India, were used as the study material. The dissection was carried out as per the guidelines given in Cunningham's dissection manual.[23] Normal anatomy and any variation in formation of plantar arterial arch were noted. Normal anatomy and any variation in origin of the PMTAs were noted. Those variations regarding variations in origin of PMTAs and fibular marginal plantar arteries were classified into six types. The classification is explained in [Table 1]. Photographs of dissected specimens were taken. The authors also tried to locate the arch in relation with length of the foot. The foot length was taken (in centimeter) as the distance between the posterior margin of the foot and the tip of the middle toe in front. Distance between the center of the arch and the posterior margin of the foot was measured in centimeters. All distances were measured with the help of measuring tape. The authors also noted the presence of medial plantar artery, fibular plantar marginal artery, and any variation in them.
Table 1: Classification of variations seen in origin of plantar metatarsal arteries either from deep plantar branch of dorsalis pedis artery or from lateral plantar artery forming the plantar arterial arch (mentioned with percentage of feet showing the variations)

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  Results Top


In 2% of cases, there was a common stump of origin for the first plantar and dorsal metatarsal arteries [Figure 1]. Common stump of origin for the first and second PMTAs [Figure 5] was seen in 2% of specimens. Common stump of origin for the second and third PMTAs [Figure 3] was seen in 10% of specimens and also for the third and fourth PMTAs [Figure 2] was found in 8% of specimens. In 2% of specimens, there was common stump of origin for the second and third PMTAs and extra third PMTA was originating from plantar arterial arch [Figure 6]. Both of them joined to form single third PMTA.
Figure 1: Type C (14%): First, second, and third PMTAs originating from deep plantar branch of dorsalis pedis artery and fourth PMTA and FPMA originating from lateral plantar artery forming plantar arterial arch. LPA: Lateral plantar artery, FPMA: Fibular plantar marginal artery, PMTAs: Plantar metatarsal arteries (1, 2, 3, and 4), *Plantar arterial arch, #first dorsal metatarsal artery, •common stump of origin for the first dorsal and first plantar metatarsal arteries

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Figure 2: Type D (24%): First and second PMTAs originating from deep plantar branch of dorsalis pedis artery and third and fourth PMTAs and FPMA originating from lateral plantar artery forming plantar arterial arch. Medial plantar artery joining first PMTA. LPA: Lateral plantar artery, *Plantar arterial arch, FPMA: Fibular plantar marginal artery, PMTAs: Plantar metatarsal arteries (1, 2, 3, and 4), #common stump of origin for third and fourth PMTAs

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Figure 3: Type E (44%): First PMTs originating from deep plantar branch of dorsalis pedis artery and second, third, and fourth PMTAs and FPMA originating from lateral plantar artery forming plantar arterial arch. LPA: Lateral plantar artery, *Plantar arterial arch, FPMA: Fibular plantar marginal artery, PMTAs: Plantar metatarsal arteries (1, 2, 3, and 4), #Common stump of origin for second and third PMTAs

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Figure 4: Type F (18%): First, second, third, and fourth PMTAs and FPMA originating from lateral plantar artery forming plantar arterial arch. LPA: Lateral plantar artery, FPMA: Fibular plantar marginal artery, PMTAs: Plantar metatarsal arteries, *Plantar arterial arch

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Figure 5: #Common stump of origin for 1st and 2nd PMTAs. LPA: Lateral plantar artery, PMTAs: Plantar metatarsal arteries. *Plantar arterial arch, 1: First plantar metatarsal artery, 2: Second plantar metatarsal artery, 3: Third plantar metatarsal artery, 4: Fourth plantar metatarsal artery

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Figure 6: Double (1 and 2) third plantar metatarsal arteries joining to form single trunk. LPA: Lateral plantar artery, *Plantar arterial arch

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In 30% of cases, the medial plantar artery was dividing into two branches: medial one was supplying medial side of the great toe and the lateral branch was passing on the deeper aspect at the first cleft to join the first dorsal metatarsal artery which divided into plantar digital branches supplying adjacent sides of the great toe and the second toe [Figure 2].

We also observed communication between the plantar arterial arch and the arcuate artery on the dorsum of the foot connected by the perforating arteries traveling in the space between the metatarsals. Fibular plantar marginal artery was present in all specimens and was branch of lateral plantar artery.


  Discussion Top


Our study correlates with a study done by Varalakshmi et al.[25] regarding type A and type D regarding type A and type D [Table 3]. In the present study, the lateral plantar artery is showing dominance in giving origin to PMTAs in 44% of feet second, third, and fourth PMTAs and fibular plantar marginal artery originating from plantar arterial arch where lateral plantar artery is dominant and also in 24% of feet third and fourth PMTAs and fibular plantar marginal artery originating from plantar arterial arch where lateral plantar artery is dominant in 44% of feet lateral three PMTAs and fibular plantar marginal artery are branches of that part of plantar arterial arch which is derived from lateral plantar artery. In 24% of feet, third and fourth PMTAs, fibular plantar marginal artery are branches of that part of plantar arterial arch which is derived from lateral plantar artery. This observation shows that in almost 68% of feet, the lateral plantar artery is dominantly supplying to most of the part of the sole through the plantar digital branches We have also describe the location of plantar arterial arch in relation to foot length which is tabulated in [Table 2].. In 28% of feet the foot length was ranging between 21.1 to 22cm and the distance between the plantar arterial arch and the posterior margin of the heel of the foot was in the range of 12 to 13.5 cm.
Table 2: Location of the plantar arterial arch in relation to foot length

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Table 3: Comparison of percentage of variations found in various studies done on origin of plantar metatarsal arteries either from deep plantar branch of dorsalis pedis artery or from lateral plantar artery forming the plantar arterial arch (mentioned with percentage of feet showing the variations)

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The authors are the first to describe the location of the plantar arterial arch in relation to foot length with a reference range of 1 cm. For the same reason, it is not possible to compare results with other studies. Knowledge of the positioning of the plantar arterial arch is crucial to surgeons when performing amputations of the forefoot or using the course of the artery as a landmark in surgical procedures and when dealing with the biomechanics of the foot.[26]

Manzi et al. (2011) so state that the medial plantar, lateral plantar, and dorsalis pedis arteries also might jointly supply the first toe. Our study correlates with a study done by Manzi et al. for the blood supply to the great toe. In patients with critical limb ischemia and an ischemic wound of the first toe, special care must be taken at preprocedural angiography to accurately determine which artery provides the dominant supply to the first toe either from dorsalis pedis artery or from the posterior tibial artery through its plantar branches. This information is crucial for ensuring an optimal supply to the wound when direct in-line flow is restored.[27]


  Conclusion Top


We have tried to notify most of the rare variations in the PMTAs, plantar arterial arch, and blood supply to the great toe. With increased use of all noninvasive procedures in endovascular surgeries, there is scope to describe minute details of normal anatomy and anatomical variations which can be of great help to the endoscopic surgeons. The information mentioned about the anatomical explanations in this article may help the surgeons to get an uneventful postoperative outcome.

Financial support and sponsorship

The study was carried out in the Department of Anatomy of Dr. D Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune. Hence, there was no separate financial support provided for the same.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mustapha JA, Katzen BT, Neville RF, Lookstein RA, Zeller T, Miller LE, et al. Critical limb ischemia is a threat to life and limb. Endovasc Today 2019;18:80-2.  Back to cited text no. 1
    
2.
Murabito JM, Evans JC, Nieto K, Larson MG, Levy D, Wilson PW. Prevalence and clinical correlates of peripheral arterial disease in the Framingham Offspring Study. Am Heart J 2002;143:961-5.  Back to cited text no. 2
    
3.
Uccioli L, Meloni M, Izzo V, Giurato L, Merolla S, Gandini R. Critical limb ischemia: Current challenges and future prospects. Vascular Health Risk Manag 2018:14;63-74.  Back to cited text no. 3
    
4.
Bosiers M, Hart JP, Deloose K, Verbist J, Peeters P. Endovascular therapy as the primary approach for limb salvage in patients with critical limb ischemia: Experience with 443 infrapopliteal procedures. Vascular 2006;14:63-9.  Back to cited text no. 4
    
5.
Gargiulo M, Giovanetti F, Bianchini Massoni C, Freyrie A, Faggioli G, Muccini N, et al. Bypass to the ankle and foot in the era of endovascular therapy of tibial disease. Results and factors influencing the outcome. J Cardiovasc Surg (Torino) 2014;55:367-74.  Back to cited text no. 5
    
6.
Papavassiliou VG, Walker SR, Bolia A, Fishwick G, London N. Techniques for the endovascular management of complications following lower limb percutaneous transluminal angioplasty. Eur J Vasc Endovasc Surg 2003;25:125-30.  Back to cited text no. 6
    
7.
Manzi M, Fusaro M, Ceccacci T, Erente G, Dalla Paola L, Brocco E. Clinical results of below-the knee intervention using pedal-plantar loop technique for the revascularization of foot arteries. J Cardiovasc Surg (Torino) 2009;50:331-7.  Back to cited text no. 7
    
8.
Manzi M. Pedal-plantar loop technique A new method for revascularization of foot vessels. Endovascular Today 2009;62-5.  Back to cited text no. 8
    
9.
Fusaro M, Paola LD, Brigato C, Marangotto M, Nicolini S, Ripay R, et al. Plantar to dorsalis pedis artery subintimal angioplasty in a patient with critical foot ischemia: A novel technique in the armamentarium of the peripheral interventionist. J Cardiovasc Med (Hagerstown) 2007;8:977-80. .  Back to cited text no. 9
    
10.
Palena LM, Manzi M. Extreme below-the-knee interventions: Retrograde transmetatarsal or transplantar arch access for foot salvage in challenging cases of critical limb ischemia. J Endovasc Ther 2012;19:805-11.  Back to cited text no. 10
    
11.
Davidson JT 3rd, Callis JT. Arterial reconstruction of vessels in the foot and ankle. Ann Surg 1993;217:699-708.  Back to cited text no. 11
    
12.
Lea Thomas M, Tanqueray AB, Burnand KG. Visualization of the plantar arch by aortography: Technique and value. Br J Radiol 1988;61:469-72.  Back to cited text no. 12
    
13.
Nakama T, Watanabe N, Kimura T, Ogata K, Nishino S, Furugen M, et al. Clinical Implications of Additional Pedal Artery Angioplasty in Critical Limb Ischemia Patients With Infrapopliteal and Pedal Artery Disease. J Endovasc Ther 2016;23:83-91.  Back to cited text no. 13
    
14.
Nakama T, Watanabe N, Haraguchi T, Sakamoto H, Kamoi D, Tsubakimoto Y, et al. Clinical outcomes of pedal artery angioplasty for patients with ischemic wounds: Results from the multicenter RENDEZVOUS registry. JACC Cardiovasc Interv 2017;10:79-90.  Back to cited text no. 14
    
15.
Kawarada O, Fujihara M, Higashimori A, Yokoi Y, Honda Y, Fitzgerald PJ. Predictors of adverse clinical outcomes after successful infrapopliteal intervention. Catheter Cardiovasc Interv 2012;80:861-71.  Back to cited text no. 15
    
16.
Rashid H, Slim H, Zayed H, Huang DY, Wilkins CJ, Evans DR, et al. The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome. J Vasc Surg 2013;57:1219-26.  Back to cited text no. 16
    
17.
Troisi N, Turini F, Chisci E, Ercolini L, Frosini P, Lombardi R, et al. Pedal arch patency and not direct-angiosome revascularization predicts outcomes of endovascular interventions in diabetic patients with critical limb ischemia. Int Angiol 2017;36:438e44.  Back to cited text no. 17
    
18.
Troisi N, Turini F, Chisci E, Ercolini L, Frosini P, Lombardi R, et al. Impact of Pedal Arch Patency on Tissue Loss and Time to Healing in Diabetic Patients with Foot Wounds Undergoing Infrainguinal Endovascular Revascularization. Korean J Radiol 2018;19:47-53.  Back to cited text no. 18
    
19.
Yamada T, Gloviczki P, Bower TC, Naessens JM, Carmichael SW. Variations of the arterial anatomy of the foot. Am J Surg 1993;166:130-5.  Back to cited text no. 19
    
20.
Standring S. Ankle and Foot, Grays Anatomy the Anatomical Basis of Clinical Practice. Ch. 84. 41th ed.. Elsevier publications; 2016. p. 1445, 1446.  Back to cited text no. 20
    
21.
Datta AK. The sole of the Foot, Part III, Essentials of Human Anatomy Superior and Inferior Extremities. Ch. 21., 3rd ed.. Kolkata: Current Books International; printed by Unik Graphic; 2004. p. 2, 14-215.  Back to cited text no. 21
    
22.
Sarrafian SK. Anatomy of the foot and ankle-Descriptive, topographic, functional. JB: Lippincott Company, Philadelphia; 1983. p. 281-91.  Back to cited text no. 22
    
23.
Romanes GJ. Cunningham's Manual of Practical Anatomy. Vol. 1, 15th edition. printed in India by Thomson Press; 1986 02-11.  Back to cited text no. 23
    
24.
Anupama K, Saraswathi G, Shetty S. A study of plantar arterial arch with its surgical perspective. Int J Anat Res 2016;4:2392-96.  Back to cited text no. 24
    
25.
Varalakshmi KL, Afroze KH, Sangeeta M Surgical implications of variations and location of plantar arterial arch: An anatomical study. Academia Anatomica Int 2019;5:95-9.  Back to cited text no. 25
    
26.
Kalicharan A, Pillay P, Rennie C, Haffajee MR. The anatomy of the plantar arterial arch. Int J Morphol 2015;33:36-42.  Back to cited text no. 26
    
27.
Manzi M, Cester G, Palena LM, Alek J, Candeo A, Ferraresi R. Vascular imaging of the foot: The first step toward endovascular recanalization. Radiographics 2011;31:1623-36.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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