1. 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

2. 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.

3. 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

4. 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

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

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

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

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

9. Angiosomes of the Leg Clinical Implications?

10. 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

11. 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

12. 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

13. 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

14. Pattern of Revascularization 43 Wounds

15. 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):

16. Outflow (Target) Artery
42%
33%
25%

17. 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%)

18. Results Outcome of initial cohort

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

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

21. 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)

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

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

24. Thank you