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

4/5/2014 1

Angiosome-Based Revascularization in CLI: Myth or Reality?

Michael S. Conte MD UCSF Vascular Symposium 2014

Disclosures

• Cook Medical- scientific advisor DCB program
• Medtronic – scientific advisor DCB program

Angiosomes and Foot Ulcers

D i r e c t r e v a s c u . . . M

• s

t d i a b e t i c . . . H e e l u l c e r s c

• .

. . F

• t

i n c i s i

• n

s . . . T h e m e d i a l p l a . . .

8% 8% 33% 21% 29%

A. Direct revascularization for an ulcer in the first web space is achieved by targeting the anterior tibial but not the posterior tibial angiosome B. Most diabetic foot ulcers can be assigned to a single dominant angiosome C. Heel ulcers correspond to the posterior tibial artery D. Foot incisions are best made along the border between adjacent angiosomes E. The medial plantar angiosome encompasses most

• f the sole of the foot

Angiosomes and Foot Ulcers

Heel ulceratio... Peroneal arter... Bypass graft p... Wound healing ...

5% 73% 14% 9%

A. Heel ulceration is a contraindication to dorsalis pedis bypass B. Peroneal artery revascularization is inferior to anterior or posterior tibial revascularization in diabetic patients with forefoot tissue loss C. Bypass graft patency and limb salvage are directly related to pedal runoff scores D. Wound healing in the foot is faster with direct revascularization

4/5/2014 2 Angiosome-targeted Revascularization

• 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?

Posterior Tibial Angiosomes (3) Peroneal Angiosomes (2)

4/5/2014 3 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

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Aerden D et al. Int J Vasc Med 2014

Location of Neuroischemic Wounds

• Patients referred to UCSF Center for Limb

Preservation (N=91) with neuroischemic wounds

J Vasc Surg 1999; 30:499-508 J Vasc Surg 1999; 30:499-508

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J Vasc Surg 2013;57:1219-26 J Vasc Surg 2013;57:1219-26

Is the pedal arch more important than the angiosome?

J Vasc Surg 2014;59:121-8

• 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

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• 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)

Varela et al Vasc Endovasc Surg 2010;44(8) 654-60

J Vasc Surg 2013;57:427-35

“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

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Conclusions

• In patients requiring revascularization for neuroischemic

foot wounds, only 50% or less of the lesions may be assigned to a specific and distinct angiosome

• Toe and forefoot lesions have dual AT/PT supply, but are

also often successfully healed with peroneal revasc

• Direct vs indirect revascularization may improve speed

and completeness of wound healing, but does not have a major impact on patency or AFS

• Quality of the pedal arch is important for wound healing,

but has minimal influence on graft patency, or AFS

• Angiosome-guided strategies may be most relevant for

midfoot and hindfoot lesions in patients undergoing endovascular approaches

Angiosomes and Foot Ulcers

• 1. Direct revascularization for an ulcer in the first web

space is achieved by targeting the anterior tibial but not the posterior tibial angiosome

• 2. Most diabetic foot ulcers can be assigned to a single

dominant angiosome

• 3. Heel ulcers correspond to the posterior tibial artery
• 4. Foot incisions are best made along the border

between adjacent angiosomes

• 5. The medial plantar angiosome encompasses most
• f the sole of the foot

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