Endovascular Management of Tibial Occlusive Disease With Concomitant Metatarsal Pseudoaneurysm and Arteriovenous Fistula in a Diabetic Foot: A Limb Salvage Case

Background Diabetic foot ulcers (DFUs) complicated by critical limb ischemia (CLI) present a major therapeutic challenge, especially when associated with chronic total occlusions (CTOs) of below-the-knee (BTK) arteries or vascular lesions such as pedal pseudoaneurysms and arteriovenous fistulas (AVFs). While endovascular techniques have expanded the therapeutic landscape, such anatomically complex cases require tailored, multidisciplinary strategies to achieve successful limb salvage. Case Presentation We report the case of a 52-year-old male with type II diabetes mellitus, end-stage renal disease (ESRD), and a chronic non-healing DFU. Imaging revealed a CTO of the posterior tibial artery (PTA) and pedal–plantar loop, significant stenosis of the dorsalis pedis artery (DPA), and a distal metatarsal artery pseudoaneurysm with an AVF. The patient underwent successful retrograde endovascular recanalization using the pedal–plantar loop technique and flossing-wire method, followed by balloon angioplasty of the DPA and PTA. Coil embolization of the pseudoaneurysm and AVF was performed using a sandwich technique. Outcome The patient experienced no peri-procedural complications. Perfusion parameters improved significantly, and complete wound healing was achieved during follow-up. No recurrence, re-intervention, or amputation occurred within 12 months. Conclusion This case highlights the feasibility and effectiveness of a fully endovascular, hybrid approach for managing complex BTK occlusions combined with distal vascular lesions. The integration of revascularization and targeted embolization in a single session can optimize outcomes in patients with limb-threatening DFUs.