Disclosures Angiosome-Based Revascularization in CLI: Myth or - PowerPoint PPT Presentation

4/5/2014 Disclosures Angiosome-Based Revascularization in CLI: Myth or Reality? •Cook Medical- scientific advisor DCB program •Medtronic – scientific advisor DCB program Michael S. Conte MD UCSF Vascular Symposium 2014 Angiosomes and Foot Ulcers Angiosomes and Foot Ulcers A. Direct revascularization for an ulcer in the first web A. Heel ulceration is a contraindication to dorsalis pedis bypass space is achieved by targeting the anterior tibial B. Peroneal artery revascularization is inferior to anterior or but not the posterior tibial angiosome posterior tibial revascularization in diabetic patients with 33% B. Most diabetic foot ulcers can be assigned to a forefoot tissue loss 29% single dominant angiosome C. Bypass graft patency and limb salvage are directly related to C. Heel ulcers correspond to the posterior tibial pedal runoff scores 21% 73% artery D. Wound healing in the foot is faster with direct D. Foot incisions are best made along the border revascularization 8% 8% between adjacent angiosomes E. The medial plantar angiosome encompasses most 14% 9% of the sole of the foot 5% . . . . . . . . . . . . . . . u o s a c c c n l t i p s e s o a r i l v b e s a i e a c c d i r i l n d u e t i m c t l t e s e o o e o e r Heel ulceratio... Peroneal arter... D i M H F h Bypass graft p... Wound healing ... T 1

4/5/2014 Angiosome-targeted Revascularization Posterior Tibial Angiosomes (3) • Rationale based on anatomic (cadaver) studies from Taylor, subsequent work from Attinger – Normal extremities without atherosclerosis • Foot has 6 angiosomes- posterior tibial (3), anterior tibial (1), peroneal (2) • Multiple “choke vessels” link angiosomes • Pedal arch anatomy plays a key role in foot • Principle is to optimize perfusion to area of ulcer • How easily are lesions assigned to angiosomes? • “Direct” versus “Indirect” revascularization- does it matter? Peroneal Angiosomes (2) 2

4/5/2014 Anterior Tibial Angiosomes (1) Angiosome-targeted Revascularization • Bypass surgery data suggests equivalent effectiveness of tibial and peroneal grafts in advanced CLI and foot wounds • Majority of toe and forefoot lesions may be within either dorsal or plantar angiosomes • Angiosome targeting be most relevant for proximal (hindfoot, ankle) lesions • May have greatest relevance for endovascular strategies where operator is selecting an infrapopliteal target to attempt recanalization Aerden D et al. Int J Vasc Med 2014 Aerden D et al. Int J Vasc Med 2014 3

4/5/2014 Location of Neuroischemic Wounds • Patients referred to UCSF Center for Limb Preservation (N=91) with neuroischemic wounds Aerden D et al. Int J Vasc Med 2014 J Vasc Surg 1999; 30:499-508 J Vasc Surg 1999; 30:499-508 4

4/5/2014 Is the pedal arch more important than the angiosome? J Vasc Surg 2013;57:1219-26 J Vasc Surg 2013;57:1219-26 • Retrospective review of infrapopliteal bypass for wounds (N=106) • 36% of wounds corresponded to a single angiosome • 33% complete pedal arch • 54DR, 52 IR • DR predicted wound healing (OR 2.9; 1.1-7.4) and healing time • AFS and overall survival no different J Vasc Surg 2014;59:121-8 J Vasc Surg 2014;59:121-8 5

4/5/2014 •Single center retrospective series of 76 limbs with ischemic ulcers treated with surgical (41) or endovascular (35) revascularization of a single tibial vessel with direct flow to the foot •Categorized intrapoperative angiograms and wounds •“Direct revascularization” •“Indirect revascularization”- fed an unrelated angiosome •“IR via collaterals”- presence of visible collaterals to the affected angiosome •Ulcer healing at 12 months •92% DR vs 73% IR (.008) •92% DR vs 85% IRc (NS) J Vasc Surg 2013;57:427-35 Varela et al Vasc Endovasc Surg 2010;44(8) 654-60 “ Our systemic review of available literature demonstrates that there is limited data available to substantiate an angiosome-based model of revascularization….” EJVES 2014 In Press 6

4/5/2014 Conclusions Angiosomes and Foot Ulcers • In patients requiring revascularization for neuroischemic 1. Direct revascularization for an ulcer in the first web foot wounds, only 50% or less of the lesions may be space is achieved by targeting the anterior tibial but assigned to a specific and distinct angiosome • Toe and forefoot lesions have dual AT/PT supply, but are not the posterior tibial angiosome also often successfully healed with peroneal revasc 2. Most diabetic foot ulcers can be assigned to a single • Direct vs indirect revascularization may improve speed dominant angiosome and completeness of wound healing, but does not have a 3. Heel ulcers correspond to the posterior tibial artery major impact on patency or AFS • Quality of the pedal arch is important for wound healing, 4. Foot incisions are best made along the border but has minimal influence on graft patency, or AFS between adjacent angiosomes • Angiosome-guided strategies may be most relevant for 5. The medial plantar angiosome encompasses most midfoot and hindfoot lesions in patients undergoing of the sole of the foot endovascular approaches Angiosomes and Foot Ulcers 1. Heel ulceration is a contraindication to dorsalis pedis bypass 2. Peroneal artery revascularization is inferior to anterior or posterior tibial revascularization in diabetic patients with forefoot tissue loss 3. Bypass graft patency and limb salvage are directly related to pedal runoff scores 4. Wound healing in the foot is faster with direct revascularization 7