Endovascular Revascularization of Symptomatic Superficial Femoral Artery (SFA) Occlusion After Below-Knee Amputation Despite Absent Distal Runoff.

Peripheral arterial disease is a major cause of morbidity, with revascularization traditionally aimed at limb preservation and prevention of major amputation. However, management strategies are less clearly defined once amputation has already occurred. In patients with a prior below-knee amputation, the clinical significance of restoring proximal arterial inflow in the absence of a distal limb remains uncertain. We present a 73-year-old man with a history of peripheral arterial disease who developed subacute, progressive pain in his residual limb along with a stump wound approximately one year after a left below-knee amputation. He had previously been ambulatory with a prosthesis and functionally independent. Examination demonstrated localized tenderness and erythema without signs of infection, and laboratory studies were unremarkable. Vascular imaging revealed complete occlusion of the superficial femoral artery without distal reconstitution, consistent with multilevel arterial occlusion and absence of a conventional distal target for revascularization. Initial endovascular attempts revealed a high thrombus burden with minimal restoration of flow following angioplasty. A staged approach was therefore pursued, consisting of catheter-directed thrombolysis followed by repeat angiography, mechanical thrombectomy, and adjunctive balloon angioplasty. Despite the absence of distal runoff, successful recanalization of the superficial femoral and popliteal arteries was achieved, with improved perfusion to the residual limb through collateral pathways. The patient experienced rapid resolution of stump pain following intervention and was able to resume ambulation with his prosthesis prior to discharge. At short-term follow-up, he remained asymptomatic with preserved functional independence. This case is hypothesis-generating and suggests that, in highly selected post-amputation patients, restoration of proximal arterial inflow may improve collateral-dependent perfusion, relieve ischemic symptoms, and preserve prosthetic function despite absent distal runoff. Because this represents a single subacute ischemic presentation without standardized perfusion metrics or long-term patency data, the findings should be interpreted cautiously within an individualized risk-benefit framework.