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The angiosome theory to guide revascularization for CLI
Richard F. Neville, MD Associate Director, INOVA Heart and Vascular Institute Vice Chairman, Department of Surgery Director, Vascular Services
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Scientific Advisory Board:
Richard F. Neville, MD Disclosures Scientific Advisory Board: WL Gore Graftworx Cormatrix Tissue Analytics
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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
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Angiosomes of the lower leg and foot
Six distinct angiosomes: Anterior tibial artery (1) Dorsalis pedis Peroneal artery (2) Lateral calcaneal Anterior perforator Posterior tibial artery (3) Calcaneal Medical plantar Lateral plantar 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. Cadaveric dissection with colored latex injections Attinger CE, et al. Plastic and Reconstr Surg 2006:117;261S-293S 4
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Angiosome: Anterior Tibial Artery
Dorsalis pedis Anterior compartment Dorsum of foot
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Angiosome: Peroneal Artery
Lateral calcaneal Lateral ankle Lateral plantar heel Anterior perforator Medial ankle
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Angiosome: Posterior Tibial Artery
Medial plantar Lateral plantar Calcaneal Lateral ankle/forefoot
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Angiosome: Indirect connections
“Choke vessels” Importance of intact pedal arch
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Does it make a difference in real world practice?
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Angiosome based revascularization Implications for healing
60 consecutive ischemic lower extremity wounds Bypass for revascularization Preoperative arteriograms Arterial anatomy relative to each wound’s angiosome Bypass anatomy Bypass anatomy relative to each wound’s angiosome Standardized wound care per protocol Neville RF, et al. Ann Vasc Surg 2009; 23(3):
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Angiosome based revascularization Direct vs Indirect
Direct Revascularization (DR) Bypass to the artery perfusing the angiosome in which the wound was located Indirect Revascularization (IR) Bypass to an artery not directly perfusing the angiosome in which the wound was located IR DR
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Angiosome based revascularization Patient Demographics
IR Male Female 48% 52% 45% 55% Diabetes Mellitus 85% 89% Hypertension 32% CHF 10% 13% CAD 27% 31% Renal Failure Diabetes and ESRD similar between groups
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Angiosome based revascularization Target artery
100% tibial bypasses No difference between groups
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Angiosome based revascularization Soft tissue / Wound Care
IR Primary closure / STSG 35% 24% Local amputation Ray/TMA/Chopart 60% 69% Free flap 5% 7% No difference in wound care between groups
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Angiosome based revascularization Degree of healing
Better complete healing with direct revascularization of the appropriate angiosome Direct revascularization Indirect revascularization 91% 62% P = 0.03 15
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Angiosome based revascularization Time to healing
Trend for faster healing with direct angiosome revascularization 16
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Angiosomes and bypass Oregon Health Sciences University
Single center, 106 limbs Complete healing (p=.001) DR 78% IR 46% Time to healing (p=.002) DR 99 days IR days “DR is a significant predictor for wound healing and reduced healing time” Kret et al. J Vasc Surg 2014;59:1:121-8.
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Angiosomes and bypass 58 bypasses DR 36, IR 22
Crural bypass for tissue loss Healing time shorter in the DR group 56 days vs 112 days Limb salvage higher in DR group 1 year: 91% vs. 66% 3 years: 65% vs. 24% 5 years: 58% vs. 18% “Achieving direct arterial flow based on the angiosome concept appears to be important for ulcer healing and limb salvage” Lejay A, et al. Ann Vasc Surgery 2014;28(4):983-9.
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Angiosomes and endovascular therapy
203 ischemic ulcers Procedures Iliac PTA 17% SFA stenting 54% Tibial PTA 82% Healing DR 86% IR 69% Iida, et al. Endo Today 2010;September:
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Angiosomes and endovascular therapy
Healing of diabetic ischemic ulcers after endovascular revascularization DR 83% healed IR 59% healed “An angiosome model of perfusion, helps the treatment of diabetic foot ulcers” Alexandrescu, et al. J Endovasc Therapy 2008;15:580
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Angiosomes for diabetic ulcers Helsinki University Hospital, Finland
250 patients, single center Ischemic diabetic ulcers Endovascular revascularization Infrapopliteal Healing at 12 months (p < .001) DR 72% IR 45% “The angiosome model is important for ulcer healing in diabetic patients” Soderstrom M, et al. J Vasc Surg 2013;57:
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Angiosome revascularization for CLI Institute of Vascular Science, Bangalore, India
Prospective study 64 patients with CLI Bypass 61%, Endovascular 39% Healing at 3 / 6 months (p=.021) DR 58% / 96% IR 13% / 83% “Angiosome should be considered whenever possible” Kabra et al. J Vasc Surg 2013;57(1):44-49.
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Summary: Angiosomes are significant
Direct revasc Indirect revasc Method Neville 91 62 Bypass Lejay 66 Alexandrescu 83 59 Endovascular Iida 86 69 Kret 78 46 Kabra 96 Bypass/Endo Soderstrom 72 45 Over 700 limbs studied
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Conclusion Angiosome concept does have practical significance
Revascularization of the appropriate wound angiosome does result in increased healing The angiosome concept should be considered in planning revascularization for healing and limb preservation
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Thank you
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