The Use of the Angiosome Concept for Treating Infrapopliteal Critical Limb Ischemia through Interventional Therapy and Determining the Clinical Significance of Collateral Vessels

doi:10.1016/j.avsg.2015.09.021

Annals of Vascular Surgery

Volume 32, April 2016, Pages 41-49

https://doi.org/10.1016/j.avsg.2015.09.021 Get rights and content

Background

The purpose of this study was to evaluate the clinical significance of the involvement of collateral vessels in interventional therapy based on the angiosome concept for infrapopliteal critical limb ischemia (CLI).

Methods

We enrolled 486 patients with unilateral infrapopliteal CLI (Rutherford Stage 5 or 6) treated at 2 hospitals from January 2005 to December 2014. Using the angiosome concept, the patients were categorized into 3 groups: the direct revascularization (DR) group, the indirect revascularization through collaterals (IR-tc) group, and the indirect revascularization without collaterals (IR-wc) group. The data from 1 year of follow-up after the initial surgery were analyzed for all 3 groups.

Results

During the 1-year follow-up, the unhealed ulcer rate of the IR-wc group was significantly higher than that of the DR group (83.4% vs. 31.7%, P < 0.001) and the IR-tc group (83.4% vs. 34.8%, P < 0.001). Furthermore, the limb salvage rate of the IR-wc group was significantly lower than that of the DR group (70.4% vs. 89.2%, P < 0.001) and the IR-tc group (70.4% vs. 85.4%, P = 0.0013). However, there were no differences in the unhealed ulcer rate or the limb salvage rate between the DR group and the IR-tc group (31.7% vs. 34.8%, P = 0.096 and 89.2% vs. 85.4%, P = 0.2834, respectively). In addition, within the IR-wc group, the unhealed ulcer rate of diabetic patients was higher than that of patients without diabetes (90.0% vs. 74.6%, P = 0.0116), but there was no difference in the limb salvage rate between diabetic and nondiabetic patients. No differences in the unhealed ulcer rate or the limb salvage rate were found between diabetic and nondiabetic patients in the other 2 groups.

Conclusions

Following the angiosome model of perfusion for endovascular therapy, directly revascularizing the feeding artery and indirectly achieving revascularization through collaterals can effectively prompt the healing of ulcers and decrease the amputation rate in patients with infrapopliteal CLI. Collateral vessels play a crucial role in the treatment of ischemic foot.

Introduction

Critical limb ischemia (CLI), the end stage of peripheral artery disease, has a direct impact on quality of life and the limb salvage rate. Currently, with the aging population and an increasing incidence of diabetes mellitus (DM), infrapopliteal CLI is receiving increasing attention.¹ The main clinical symptoms of infrapopliteal CLI are pain while resting, unhealed foot ulcers, and gangrene. Endovascular therapy has dramatically improved in recent years and has been gradually implemented as the first treatment option for infrapopliteal CLI because of its advantages, such as safety, efficacy, and repeatability.2, 3

Currently, the angiosome concept is widely researched in the field of infrapopliteal CLI endovascular therapy. In 1987, Taylor introduced the angiosome concept, which divides the infrapopliteal area into 3 source arteries (SAs) and 6 anatomic regions (angiosomes). Additionally, he defined direct revascularization (DR) as the revascularization of at least one feeding vessel that supplies the ischemic angiosome and indirect revascularization (IR) as the revascularization of a feeding vessel in an unrelated angiosome that can also restore the blood flow of the injured angiosome.⁴ Several studies have proposed that treatment based on the angiosome concept is the key for curing infrapopliteal CLI, but the clinical significance remains controversial. Two meta-analyses by Biancari and Juvonen and Bosanquet et al. suggested that DR results in better wound healing and a higher limb salvage rate than IR.5, 6 However, other recent studies showed that DR had a significantly better rate of wound healing but a similar limb salvage rate when compared with IR.7, 8, 9 Of note, the status of collateral vessels was not analyzed in these studies. Summarizing the above results, the differences among the previous studies may partly be explained by the collateral circulation of patients with infrapopliteal CLI in compensation, especially in the IR group.

This study compared the differences in the clinical outcomes of patients with infrapopliteal CLI treated with DR and IR and then further evaluated the clinical significance of the collateral vessels in endovascular therapy based on the angiosome concept.

Section snippets

Patients

Our study retrospectively analyzed patients with unilateral infrapopliteal CLI treated at the First Affiliate Hospital of Wenzhou Medical University and the First Affiliate Hospital of Zhejiang University from January 2005 to December 2014. All participants met all of the following enrollment criteria: (1) one or more serious symptoms of CLI, including ulcers and gangrene (Rutherford Stage 5 or 6); (2) below-knee artery stenosis or occlusion diagnosed by arteriography; and (3) successful

Clinicopathological Characteristics of the 486 Diseased Limbs

Our study enrolled 486 patients with endovascular therapy of infrapopliteal CLI between January 2005 and December 2014. All patients had Rutherford clinical stage 5/6 disease. Some diseased areas were recorded as multiple angiosomes because they were fed by at least 2 angiosomes. The ulcer/gangrene regions in the present study were mainly concentrated in the DP (61.5%), MP (40.5%), and LP (27.2%). The demographic characteristics, comorbidities, ulcer/gangrene description, and examination data

Discussion

With the development of endovascular therapy, surgical interest in below-the-knee endovascular therapy has increased. At the early stage, successful endovascular therapy is defined as reconstruction of at least one of the 3 infrapopliteal arteries. However, the clinical outcome of this technology is not satisfactory. Studies have shown that refractory ulcers are frequently observed in patients after successful revascularization of the lower limb and that these refractory ulcers result in a

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Cited by (39)

Below-the-Knee Endovascular Revascularization: A Position Statement
2024, JACC: Cardiovascular Interventions
Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.
The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer
2023, Journal of Vascular Surgery
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events.
The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries.
This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs.
Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking.
The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
Editor's Choice – The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer
2023, European Journal of Vascular and Endovascular Surgery
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events.
The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries.
This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs.
Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking.
The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
Evaluation of the Angiosome Concept Using Near-Infrared Fluorescence Imaging with Indocyanine Green
2023, Annals of Vascular Surgery
The angiosome concept is defined as the anatomical territory of a source artery within all tissue layers. When applying this theory in vascular surgery, direct revascularization (DR) is preferred to achieve increased blood flow toward the targeted angiosome of the foot in patients with lower extremity arterial disease (LEAD). This study evaluates the applicability of the angiosome concept using quantified near-infrared (NIR) fluorescence imaging with indocyanine green (ICG).
This study included patients undergoing an endovascular- or surgical revascularization of the leg between January 2019 and December 2021. Preinterventional and postinterventional ICG NIR fluorescence imaging was performed. Three angiosomes on the dorsum of the foot were determined: the posterior tibial artery (hallux), the anterior tibial artery (dorsum of the foot) and the combined angiosome (second to fifth digit). The angiosomes were classified from the electronic patient records and the degree of collateralization was classified based on preprocedural computed tomography angiography and/or X-ray angiography. Fluorescence intensity was quantified in all angiosomes. A subgroup analysis based on endovascular or surgical revascularized angiosomes, and within critical limb threatening ischemia (CLTI) patients was performed.
ICG NIR fluorescence measurements were obtained in 52 patients (54 limbs) including a total of 157 angiosomes (121 DR and 36 indirect revascularizations [IR]). A significant improvement of all perfusion parameters in both the directly and indirectly revascularized angiosomes was found (P-values between <0.001–0.007). Within the indirectly revascularized angiosomes, 90.6% of the scored collaterals were classified as significant. When comparing the percentual change in perfusion parameters between the directly and indirectly revascularized angiosomes, no significant difference was seen in all perfusion parameters (P-values between 0.253 and 0.881). Similar results were shown in the CLTI patients subgroup analysis, displaying a significant improvement of perfusion parameters in both the direct and indirect angiosome groups (P-values between <0.001 and 0.007), and no significant difference when comparing the percentual parameter improvement between both angiosome groups (P-values between 0.134 and 0.359). Furthermore, no significant differences were observed when comparing percentual changes of perfusion parameters in directly and indirectly revascularized angiosomes for both endovascular and surgical interventions (P-values between 0.053 and 0.899).
This study proves that both DR and IR of an angiosome leads to an improvement of perfusion. This suggests that interventional strategies should not only focus on creating in-line flow to the supplying angiosome. One can argue that the angiosome concept is not applicable in patients with LEAD.
The Relationship Between the Global Limb Anatomic Staging System Inframalleolar Modifier and the Outcomes of Diabetic Foot Ulcer with Peripheral Artery Disease
2023, Annals of Vascular Surgery
We aimed to investigate the relationship between the condition of the inframalleolar (IM) arteries, as assessed by the Global Limb Anatomic Staging System Inframalleolar (GLASS IM) modifier, and the outcomes of patients with diabetic foot ulcers.
The data of 215 patients, who underwent endovascular therapy from January 2016 to May 2020 at our center, were retrospectively reviewed. Patients were divided into the P0, P1, and P2 groups according to the angiography results. The rates of ulcer healing, limb salvage, survival, and amputation-free survival were compared during the 2-year period after discharge.
Of the 216 affected limbs, 35 (16%) were classed as P0, 122 (57%) as P1, and 59 (27%) as P2. Compared with the P2 group, the P0 + P1 group had a higher ulcer healing rate (P = 0.001), a shorter ulcer healing time (P = 0.004), and a higher survival rate (P = 0.044). GLASS IM Modifier classification P2 was an independent predictor of nonhealing ulcers. No significant difference was observed between the P0 versus P1 groups.
GLASS IM modifier classification P2 is an independent risk factor for a poor outcome. GLASS IM modifier classification P0 versus P1 demonstrates similar outcomes to each other.
SCAI/ACR/APMA/SCVS/SIR/SVM/SVS/VESS position statement on competencies for endovascular specialists providing CLTI care
2022, Journal of Vascular Surgery
Citation Excerpt :
At a fundamental level, the proceduralists should be able to interpret a lower extremity arteriogram and use that anatomic information to develop a revascularization strategy. Angiosome-based revascularization, while conceptually important, does have limitations that should be understood when formulating revascularization plans.30 At a more advanced level, experience and familiarity with pedal arch anatomy will aid in cases of complex CLTI.31

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: Xiang-Tao Zheng and Rui-Chao Zeng participated equally and should share “first authorship”.

: Zi-Heng Wu and Guan-Feng Yu participated equally and should share “corresponding authorship”.

: This is an original article. We certify that this manuscript has not been published previously and is not based on a previous communication to a society or meeting.

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Clinical ResearchThe Use of the Angiosome Concept for Treating Infrapopliteal Critical Limb Ischemia through Interventional Therapy and Determining the Clinical Significance of Collateral Vessels

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Clinicopathological Characteristics of the 486 Diseased Limbs

Discussion

Eur J Vasc Endovasc Surg

J Vasc Surg

J Vasc Surg

Br J Plast Surg

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

J Vasc Surg

J Vasc Surg

Eur J Vasc Endovasc Surg

Clinical Research
The Use of the Angiosome Concept for Treating Infrapopliteal Critical Limb Ischemia through Interventional Therapy and Determining the Clinical Significance of Collateral Vessels