Revascularization of a Specific Angiosome for Limb Salvage: Does the target artery matter? Richard F. Neville, MD Professor, Department of Surgery Chief, Division of Vascular Surgery George Washington University MFA

I have no real or apparent conflicts of interest to report. Richard F. Neville, MD I have no real or apparent conflicts of interest to report.

Angiosome concept Angiosome – 3D anatomic unit fed by a source artery taYLO Angiosome – 3D anatomic unit fed by a source artery Defined 40 in the body Taylor, et al. Br J Plastic Surgery 1987:40:113

Foot and Ankle Angiosomes Six distinct angiosomes: Posterior tibial artery (3) Anterior tibial artery (1) Peroneal artery (2) Cadaveric dissection The foot and ankle comprises 5 distinct angiosomes: 3 from the distal branches of the posterior tibial artery, 1 by the dorsalis pedis artery, and 1 by the peroneal artery. Attinger et al, Plast Reconstructive Surg 2006:117;261S-293S

Angiosomes: Anterior Tibial Artery Dorsalis Pedis Anterior compartment Dorsum of foot

Angiosomes: Peroneal Artery Lateral Calcaneal Lateral ankle Plantar heel Anterior Perforator Anterior ankle Lateral plantar heel Lateral ankle

Angiosome: Posterior Tibial Artery Calcaneal Branch Medial ankle Plantar heel Medial Plantar Branch Medial instep Lateral Plantar Branch Lateral forefoot Plantar forefoot Medial ankle

Angiosomes of the Leg Arterial-arterial connections (choke vessels) AT – Peroneal Lateral malleolar Ant perforating PT – Peroneal Perforating branches AT – PT Medial Plantar

Angiosomes of the Leg Clinical Implications?

Study Methods Retrospective analysis 60 consecutive non-healing lower extremity wounds 56 patients Preoperative arteriograms Arterial anatomy relative to each wound’s angiosome Lower extremity bypass Bypass anatomy relative to each wound’s angiosome Wound care per protocol Serial debridement and closure Primary closure / STSG Local amputation, Local flap, Free flap

Methods Wounds divided into two groups Direct Revascularization (Direct) Bypass performed to the artery supplying the angiosome in which the wound was located Indirect Revascularization (Indirect) Bypass performed to an artery not directly supplying the angiosome in which the wound was located

Patient Demographics Total Direct Indirect Male Female 46% 54% 48% 52% 45% 55% Diabetes Mellitus 87% 85% 89% Hypertension 39% 32% CHF 11% 10% 13% CAD 29% 27% 31% Renal Failure

Methods 8 deaths unrelated to wound treatment 52 wounds 27 Direct revascularization 25 Indirect revascularization 1 bypass failure (perioperative) 8 with incomplete follow-up 43 wounds for final analysis

Pattern of Revascularization 43 Wounds

Neville, et al. J Vasc Surg 2001;33(2):266-72. Type of Bypass 65% 35% Neville, et al. J Vasc Surg 2001;33(2):266-72.

Outflow (Target) Artery 42% 33% 25%

Wound Care Total Direct Revasc Indirect STSG Primary closure 10 (30%) 7 (35%) 3 (24%) Local amputation Ray/TMA/Chopart Local flap 21 (64%) 12 (60%) 9 (69%) Free flap 2 (6%) 1 (5%) (7%)

Results Outcome of initial cohort

Direct vs Indirect Revascularization 91% 62% 38% 9% Fisher’s exact test P = 0.03

Time to healing Direct Indirect 24 - 386 days 162 days 50 – 270 days T-test, P = 0.95

Major Amputations Total N=43 Direct N=22 Indirect N=21 Complete healing 33 20 13 Amputation 10 2 2 BKA 8 1 AKA 7 BKA Mortality unrelated to wound 9 3 6 Mean 6.25 months (range 1-14 months)

Summary Direct revascularization of the angiosome specific to wound anatomy Increased complete healing Increased limb salvage

Conclusion Factors in choosing target artery for revascularization Endovascular vs Bypass Quality of possible targets Conduit available Placement of incisions Artery feeding wound angiosome

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