Thank you very much, it's really been great cases so far. So I'm going to spend the next 10 minutes talking about pedal artery construction. We'll talk a little bit about why and how, but I think the cases are kind of the instructive part of this. Knowing that pedal anatomy is how you're going to succeed. We know that the anterior and posterior connection from the lateral plantar to the dorsalis pedis exists, but we don't always see it. We just saw a case where there was just desert foot, you don't see anything there. And these deep pedal loops or secondary pedal plantar loops connect these two segments. So just knowing that they exist means that you should be able to find them. Why reconstruct it? Because we know that intact pedal arches are associated with improved wound healing and higher patency rates for bypass, and we try to use this kind of angiosome-based revascularization, but also to understand that when they have no other options, you're going to have to try to find which pedal arch vessel is going to heal, and it's not always the one that you think goes to the wound directly. It may actually be a collateralized one, so always keep that in mind, that any pedal segment that you recantalize may actually heal the area that you're looking for. Also know how to find the different pedal vessels, I mean, understand the angiographic techniques. I'm not going to belabor this, but in the lateral views, you want to see that fifth metatarsal. Otherwise, you're probably not going to be able to see this anterior-posterior. And then in the AP view, you want to see the first metatarsal inner space, that segment between the two, because then you'll be able to tell if the pedal plantar loop is present, absent. And then you can visualize in your mind's eye where it should be as you're passing these wires down. The baseline anatomy is clear, but I think when it's absent is when it's really hard to tell where am I supposed to go and how do I get there. So we just keep these things in mind as you're doing your angiography. It's nice when you see all the vessels, but for the most part, you won't see these vessels. Also understand that there are some interesting collaterals. I'll show you a case of taking this communicating branch to the PTA, where we had no vessel to the posterior tibial, ultimately went through this collateral branch, opened up the posterior tibia, and then got the rest of the loop opened up. So you never really know which, the anterior, posterior, or perineal, is going to be your most favorable vessel, and sometimes you actually have to try all three. Direct wires, atraumatic O1-4 wires, for the most part, Command-ES are what we use. We still use some choice PTs, and then we start increasing the level of the tips. Generally speaking, we don't go with real stiff things because you want to use either direct straight wire or you want to loop these wires. Catheters generally, O1-4 wires with O1-8 support catheters. It gets you through many of these. We will pull some coronary equipment sometimes for these cases as well, and you have to have 200-centimeter shaft balloons. This is a big frustration in many labs, is that the shaft lengths aren't there, and they're not over the wire, and you oftentimes run out of space if you're going contralateral in these patients, which is frequently an issue for us. So let me show you an example. Here's a patient who had a duplex, and the angiogram really required further review because they were sent because there was no healing of this wound. ABI and TBI were low here bilaterally, and you can see the second toe in magnification. There is no second toe. These erosive changes are osteomyelitis. Patients got an angiogram with a second toe ulcer. Proximal SFA and popliteal vessels look patent. I was sent a report that said the patient has normal tibial vessels and just needs an amputation. So wait a second. Have you gotten down to the foot? So the petal arch angiogram was important to look at, and you can see here posterior tibial, anterior tibial don't connect. Patient's wound was on the second toe, so we got to keep looking. Incomplete petal arch, you do an angiogram, and you see all the way down at the foot that it looks pretty good. If you saw this, you'd say, okay, this patient should heal. But you bring the wire down and recognize that the anterior and posterior tibia are not connected. You do a roadmap image, and here comes a command wire coming from the posterior tibial down the petal arch, around the corner, and ultimately stops. You can't get it to go any further, and the patient's basically kind of writhing a little bit or wriggling on the table. So you continue a little further, and what you see is that you can take this wire and you can loop it. And this is the straight wire combined with the loop wire technique, and you find these petal arch connections and then go right back up the opposite side, and ultimately take balloons down there around the corner, 200-centimeter shaft balloons, usually two-and-a-half to three-millimeter balloons. And then you see that now you have flow, and this patient ultimately ended up healing that second toe ulcer. So the final angiogram shows that there's going to be some spasm, there's going to be some issues, but generally speaking, these do have a tendency to heal those segments. So example two is if at first you don't succeed, try, try, and try again. So here's again, anterior tibial looks like it's open, perineal and posterior tibial are gone. Here's the foot. Looks kind of deserted, and the patient's not healing a third toe and second toe ulcer. So what do we try? First, the obvious one is go down that anterior tibial and see if you can get something to go around. Well, that was a good try. We tried that. That didn't really work. So got down to the distal end of the foot, did an angiogram, didn't really see anything further, put the wire in the anterior tibial, then went across one of these cross-ankle collaterals, got this posterior tibial a little bit better opened up by balloon angioplasty. Interestingly, these are sort of built on each of the successes of the wire passing type of cases. So once you get into the posterior tibial, so now you can start seeing more. All right. Well, the anterior tibial didn't work. The posterior tibial only had access through that collateral. So let's balloon that territory and see if we can see anything a little bit better. Well, now we can see coming from the posterior tibial all the way from the top that you can get all the way around the medial malleolar branch, but you still can't go around the corner because it's just a dead end there. So you continue to take support catheter all the way down to the foot, and you look on that left side, wire goes down into the toes. I'm tickling this patient's toenails, and then ultimately that's not it. You keep feeling because you know that it's there, and this is a little bit, you see it pull the catheter back. Nope, that's not it. Pull the catheter back a little further. Nope, that's not it. And then there it is. And frequently, it takes a couple of different tries to get there, and then you can see on the right-sided screen that this will come right back up into the patient, usually moves their foot right about that time right there. And then you get back, balloon angioplasty this, and you can see now there's a complete pedal loop, and that pedal loop has now led to revascularization and ultimately to healing of that patient. Pedal arch data does suggest that incomplete pedal arches don't do as well as complete pedal arches. It's not always easy to do, and it's not always imperative that you get all of it opened up every time, but any one of those vessels improves the overall outcome of these patients and should be attempted in most of these cases. So wound management, angiosome-based intervention, working in collaboration, and just trying these wires until they get around the loop is what you should do. Thank you.

pedal artery construction

pedal anatomy

revascularization procedures

pedal arches

angiographic techniques