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Introduction: Progressive improvement in the ability to treat complete total occlusions in the tibial level arterial circulation have made it possible to revascularize patients with critical limb ischemia when open techniques may not be feasible or favored. As experience mounts in the treatment of these lesions, unexpected complications will also require the application of new techniques to salvage unexpected and potentially disastrous outcomes.
Case Report: We report a 59 year old man with critical limb ischemia of his right lower extremity manifesting as a non-healing, infected great toe ulcer who underwent peripheral arterial intervention, after failing conservative wound care. Diagnostic angiography revealed a complete total occlusion (CTO) of his anterior tibial artery (ATA) with distal reconstitution through peroneal artery collaterals. Using a variety of 0.14 and 0.18in wires and tapered crossing catheters, distal luminal re-entry was established. During an effort aimed at luminal enlargement using progressively larger angioplasty balloons, it was noted that a 2.0 x 40mm balloon (Coyote, Boston Scientific) had become detached from its shaft and was retained within the patent portion of the target vessel. Multiple efforts at balloon capture were attempted, but unsuccessful, with the retained balloon ultimately lodged in the distal ATA. While likely deflated, the balloon represented a nidus for thrombosis with likely resultant acute on chronic arterial ischemia through disruption of collaterals. Two 3.0mm drug-eluting (everolimus) coronary stents (Promus, Boston Scientific) were deployed across the length of the balloon with excellent luminal preservation. Successful CTO revascularization was completed and a strong dorsalis pedis artery pulse was restored following intervention. He underwent wound debridement and hyperbaric oxygen therapy for culture-proven osteomyelitis with complete resultant healing within one month.