Clinical implications of the angiosome model in peripheral vascular disease
2013; Elsevier BV; Volume: 58; Issue: 3 Linguagem: Inglês
10.1016/j.jvs.2013.06.056
ISSN1097-6809
AutoresBauer E. Sumpio, Rachael O. Forsythe, Kenneth R. Ziegler, Jeff G. van Baal, Mauri Lepäntalo, Robert J. Hinchliffe,
Tópico(s)Cerebrovascular and Carotid Artery Diseases
ResumoVascular surgery has seen a revolutionary transformation in its approach to peripheral vascular disease over the last 2 decades, fueled by technological innovation and a willingness by the field to adopt these changes. However, the underlying pathology behind critical limb ischemia and the significant rate of unhealed wounds and secondary amputations despite apparently successful revascularization needs to be addressed. In seeking to improve outcomes, it may be beneficial to examine our approach to vascular disease at the fundamental level of anatomy, the angiosome, to better dictate reperfusion strategies beyond a simple determination of open vs endovascular procedure. We performed a systematic review of the current literature concerning the significance of the angiosome concept in the realm of vascular surgery. The dearth of convincing evidence in the form of prospective trials and large patient populations, and the lack of a consistent, comparable vocabulary to contrast study findings, prevent recommendation of the conceptual model at a wider level for guidance of revascularization attempts. Further well-structured, prospective studies are required as well as emerging imaging strategies, such as indocyanine green dye-based fluorescent angiography or hyperspectral imaging, to allow wider adoption of the angiosome model in vascular operations. Vascular surgery has seen a revolutionary transformation in its approach to peripheral vascular disease over the last 2 decades, fueled by technological innovation and a willingness by the field to adopt these changes. However, the underlying pathology behind critical limb ischemia and the significant rate of unhealed wounds and secondary amputations despite apparently successful revascularization needs to be addressed. In seeking to improve outcomes, it may be beneficial to examine our approach to vascular disease at the fundamental level of anatomy, the angiosome, to better dictate reperfusion strategies beyond a simple determination of open vs endovascular procedure. We performed a systematic review of the current literature concerning the significance of the angiosome concept in the realm of vascular surgery. The dearth of convincing evidence in the form of prospective trials and large patient populations, and the lack of a consistent, comparable vocabulary to contrast study findings, prevent recommendation of the conceptual model at a wider level for guidance of revascularization attempts. Further well-structured, prospective studies are required as well as emerging imaging strategies, such as indocyanine green dye-based fluorescent angiography or hyperspectral imaging, to allow wider adoption of the angiosome model in vascular operations. Peripheral arterial disease (PAD) is increasing in prevalence worldwide affecting 12% to 20% of the elderly (aged 65 years and older).1Roger V.L. Go A.S. Lloyd-Jones D.M. Benjamin E.J. Berry J.D. Borden W.B. et al.Heart disease and stroke statistics–2012 update: a report from the American Heart Association.Circulation. 2012; 125: e2-e220Crossref PubMed Scopus (0) Google Scholar Critical limb ischemia (CLI) represents the most severe form of PAD and is characterized by rest pain, ulcers, or gangrene.2Novo S. Coppola G. Milio G. Critical limb ischemia: definition and natural history.Curr Drug Targets Cardiovasc Haematol Disord. 2004; 4: 219-225Crossref PubMed Scopus (116) Google Scholar In patients who have progressed to CLI, revascularization of the affected extremity through surgical bypass or endovascular intervention plays a crucial role in staving off limb loss, prolonging survival, and improving their quality of life.3Norgren L. Hiatt W.R. Dormandy J.A. Nehler M.R. Harris K.A. Fowkes F.G. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).J Vasc Surg. 2007; 45: S5-S67Abstract Full Text Full Text PDF PubMed Scopus (4328) Google Scholar Forty percent of patients with CLI who lack revascularization options face the prospect of major amputation within 1 year of diagnosis4Sumpio B.E. Foot ulcers.N Engl J Med. 2000; 343: 787-793Crossref PubMed Scopus (169) Google Scholar, 5Tang P.C. Ravji K. Key J.J. Mahler D.B. Blume P.A. Sumpio B. Let them walk! Current prosthesis options for leg and foot amputees.J Am Coll Surg. 2008; 206: 548-560Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar; mortality in these patients may be as high as 20% over this time.6Powell R.J. Update on clinical trials evaluating the effect of biologic therapy in patients with critical limb ischemia.J Vasc Surg. 2012; 56: 264-266Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar There is evidence to support either bypass surgery or primary angioplasty as first-line treatment modalities for severe and critical limb ischemia.7Adam D.J. Beard J.D. Cleveland T. Bell J. Bradbury A.W. Forbes J.F. et al.Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial.Lancet. 2005; 366: 1925-1934Abstract Full Text Full Text PDF PubMed Scopus (1604) Google Scholar Traditionally, planning for revascularization has utilized the ‘best vessel’ approach, whereby the target outflow artery is chosen based on technical suitability, disease characteristics, length of bypass required, conduit available, and patent distal vessel to anchor the bypass.8Lepantalo M. Biancari F. Tukiainen E. Never amputate without consultation of a vascular surgeon.Diabetes Metab Res Rev. 2000; 16: S27-S32Crossref PubMed Scopus (62) Google Scholar, 9Sumpio B.E. Lee T. Blume P.A. Vascular evaluation and arterial reconstruction of the diabetic foot.Clin Podiatr Med Surg. 2003; 20: 689-708Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar TASC II suggests that in the case of a femoral tibial bypass, the best vessel, regardless of location, should be used. However, there is increasing interest in the ‘angiosome model’ of revascularization for ischemic ulceration.10Alexandrescu V. Soderstrom M. Venermo M. Angiosome theory: fact or fiction?.Scand J Surg. 2012; 101: 125-131Crossref PubMed Scopus (49) Google Scholar, 11Larena-Avellaneda A. Debus S. Pflugradt A. Kolbel T. Diener H. New surgical and hybrid techniques for crural and pedal anastomoses.J Cardiovasc Surg (Torino). 2012; 53: 151-160PubMed Google Scholar, 12Verzini F. De Rango P. Isernia G. Simonte G. Farchioni L. Cao P. Results of the “endovascular treatment first” policy for infrapopliteal disease.J Cardiovasc Surg (Torino). 2012; 53: 179-188PubMed Google Scholar The angiosome concept was introduced 25 years ago in a landmark paper by Taylor and Palmer.13Taylor G.I. Palmer J.H. The vascular territories (angiosomes) of the body: experimental study and clinical applications.Br J Plast Surg. 1987; 40: 113-141Abstract Full Text PDF PubMed Scopus (1272) Google Scholar Utilizing ink injection studies, dissection, perforator mapping, and radiographic analysis of cadaveric specimens, the pair defined the angiosome as a three-dimensional network of vessels not only in the skin, but in all tissue layers between the skin and the bone. The primary supply to the skin was found to come from direct cutaneous arteries, which vary in diameter, length, and density in different areas of the body. These are reinforced by small, indirect vessels that tend to be the terminal branches of arteries that primarily supply the deeper tissues. In the zone between adjacent angiosomes,14Inoue Y. Taylor G.I. The angiosomes of the forearm: anatomic study and clinical implications.Plast Reconstr Surg. 1996; 98: 195-210Crossref PubMed Scopus (89) Google Scholar they identified reduced caliber (“choke”) or similar caliber (“true”) anastomotic arteries that provide redundant conduits to allow a given angiosome to receive blood flow from an adjacent neighboring angiosome if the source artery is compromised. Ultimately, at least 40 angiosomes in the human body were characterized, with six identified in the foot based on the three main arteries to the foot (Fig 1).14Inoue Y. Taylor G.I. The angiosomes of the forearm: anatomic study and clinical implications.Plast Reconstr Surg. 1996; 98: 195-210Crossref PubMed Scopus (89) Google Scholar, 15Attinger C.E. Evans K.K. Bulan E. Blume P. Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization.Plast Reconstr Surg. 2006; 117: 261S-293SCrossref PubMed Scopus (368) Google Scholar A systematic literature review was undertaken, using search terms including ‘angiosome,’ ‘revascularization,’ ‘critical AND limb AND ischemia,’ and ‘direct AND revascularization’ (Fig 2). No date limit was set, and all papers were fully accessed. Studies were included if they reported results of the angiosome approach to revascularization of ischemic lower limb ulceration by surgical, angioplasty, or hybrid methods. Where study findings were reported in more than one paper, duplicate results were not included.16Alexandrescu V.A. Hubermont G. Philips Y. Guillaumie B. Ngongang C. Vandenbossche P. et al.Selective primary angioplasty following an angiosome model of reperfusion in the treatment of Wagner 1-4 diabetic foot lesions: practice in a multidisciplinary diabetic limb service.J Endovasc Ther. 2008; 15: 580-593Crossref PubMed Scopus (113) Google Scholar Data was collected on demographic information including relevant comorbidities such as diabetes, end-stage renal disease, and ischemic heart disease and contributing factors such as smoking history and the presence of coexisting neuropathy. End points included limb salvage, wound healing, mortality, technical success, reintervention rate, time to ulcer healing, and major and minor amputation. In studies that compared the use of the angiosome-based direct revascularization (DR) with nonangiosome-based indirect revascularization (IR), results were taken to be significant if P ≤ .05. Eleven articles were included in the outcomes analysis, involving treatment of 1616 patients and 1757 limbs reported in papers published between 2008 and 2013 (Table I). These studies were either retrospective case series reviews or retrospective reviews of prospectively kept databases. None of the studies were randomized controlled trials. Techniques reviewed included surgical bypass only, primary angioplasty only, hybrid procedures, or both methods analyzed together. Some studies looked at primary revascularization and excluded those patients with previous interventions,17Alexandrescu V. Vincent G. Azdad K. Hubermont G. Ledent G. Ngongang C. et al.A reliable approach to diabetic neuroischemic foot wounds: below-the-knee angiosome-oriented angioplasty.J Endovasc Ther. 2011; 18: 376-387Crossref PubMed Scopus (104) Google Scholar, 18Iida O. Nanto S. Uematsu M. Ikeoka K. Okamoto S. Dohi T. et al.Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia.Catheter Cardiovasc Interv. 2010; 75: 830-836PubMed Google Scholar, 19Soderstrom M. Alback A. Biancari F. Lappalainen K. Lepantalo M. Venermo M. Angiosome-targeted infrapopliteal endovascular revascularization for treatment of diabetic foot ulcers.J Vasc Surg. 2013; 57: 427-435Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 20Varela C. Acin F. de Haro J. Bleda S. Esparza L. March J.R. The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model.Vasc Endovascular Surg. 2010; 44: 654-660Crossref PubMed Scopus (115) Google Scholar while others described the angiosome approach when used as a salvage procedure in patients with previously failed attempts at revascularization.21Alexandrescu V. Ngongang C. Vincent G. Ledent G. Hubermont G. Deep calf veins arterialization for inferior limb preservation in diabetic patients with extended ischaemic wounds, unfit for direct arterial reconstruction: preliminary results according to an angiosome model of perfusion.Cardiovasc Revasc Med. 2011; 12: 10-19Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Some studies looked retrospectively at the results of patients in whom successful revascularization had been undertaken, recording whether this had been achieved by targeting the source artery supplying the affected angiosome (equivalent to DR) or not.19Soderstrom M. Alback A. Biancari F. Lappalainen K. Lepantalo M. Venermo M. Angiosome-targeted infrapopliteal endovascular revascularization for treatment of diabetic foot ulcers.J Vasc Surg. 2013; 57: 427-435Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 20Varela C. Acin F. de Haro J. Bleda S. Esparza L. March J.R. The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model.Vasc Endovascular Surg. 2010; 44: 654-660Crossref PubMed Scopus (115) Google Scholar, 22Azuma N. Uchida H. Kokubo T. Koya A. Akasaka N. Sasajima T. Factors influencing wound healing of critical ischaemic foot after bypass surgery: is the angiosome important in selecting bypass target artery?.Eur J Vasc Endovasc Surg. 2012; 43: 322-328Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar, 23Deguchi J. Kitaoka T. Yamamoto K. Matsumoto H. Sato O. Impact of angiosome on treatment of diabetic ischaemic foot with paramalleolar bypass.J Jpn Coll Angiol. 2010; 50: 687-691Google Scholar, 24Iida O. Soga Y. Hirano K. Kawasaki D. Suzuki K. Miyashita Y. et al.Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions.J Vasc Surg. 2012; 55: 363-370.e5Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar, 25Neville R.F. Attinger C.E. Bulan E.J. Ducic I. Thomassen M. Sidawy A.N. Revascularization of a specific angiosome for limb salvage: does the target artery matter?.Ann Vasc Surg. 2009; 23: 367-373Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar Other studies compared the use of DR or IR in their patient series, recording outcomes of each technique and thereby examining whether DR is technically possible and effective for treatment of lower limb ischemic ulceration and, if so, how it compares with the results of IR.18Iida O. Nanto S. Uematsu M. Ikeoka K. Okamoto S. Dohi T. et al.Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia.Catheter Cardiovasc Interv. 2010; 75: 830-836PubMed Google Scholar, 21Alexandrescu V. Ngongang C. Vincent G. Ledent G. Hubermont G. Deep calf veins arterialization for inferior limb preservation in diabetic patients with extended ischaemic wounds, unfit for direct arterial reconstruction: preliminary results according to an angiosome model of perfusion.Cardiovasc Revasc Med. 2011; 12: 10-19Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 26Fossaceca R. Guzzardi G. Cerini P. Cusaro C. Stecco A. Parziale G. et al.Endovascular treatment of diabetic foot in a selected population of patients with below-the-knee disease: is the angiosome model effective?.Cardiovasc Intervent Radiol. 2013; 36: 637-644Crossref PubMed Scopus (44) Google Scholar, 27Kabra A. Suresh K.R. Vivekanand V. Vishnu M. Sumanth R. Nekkanti M. Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia.J Vasc Surg. 2013; 57: 44-49Abstract Full Text Full Text PDF PubMed Scopus (80) Google ScholarTable ITreatment modalityFirst authorYear of publicationCountry of studyStudy designNumber of limbs (number of patients)Treatment modality (bypass only, angioplasty only, hybrid, both)Procedure type (primary, secondary, etc)Length of follow-upOutcomes assessed (timing of assessments)Neville25Neville R.F. Attinger C.E. Bulan E.J. Ducic I. Thomassen M. Sidawy A.N. Revascularization of a specific angiosome for limb salvage: does the target artery matter?.Ann Vasc Surg. 2009; 23: 367-373Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar2009USARetrospective case series (consecutive patients)52 (48)BypassNot specifiedNot specifiedComplete wound healing, time to complete healing, major amputation, mortality (100 days, 200 days)Varela20Varela C. Acin F. de Haro J. Bleda S. Esparza L. March J.R. The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model.Vasc Endovascular Surg. 2010; 44: 654-660Crossref PubMed Scopus (115) Google Scholar2010SpainRetrospective case series (consecutive patients)76 (70)Both (angioplasty as first-line if possible)Primary procedureMedian, 427 (175-828) daysHealing time, healing rate, limb salvage, major amputation, overall survival (1, 3, 6 months then every 6 months)Iida20Varela C. Acin F. de Haro J. Bleda S. Esparza L. March J.R. The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model.Vasc Endovascular Surg. 2010; 44: 654-660Crossref PubMed Scopus (115) Google Scholar2010JapanRetrospective case series (consecutive patients)203 (177)AngioplastyPrimary procedureUp to 4 yearsLimb salvage, influence of run-off on limb salvage (1, 2, 3, 4 years)Deguchi23Deguchi J. Kitaoka T. Yamamoto K. Matsumoto H. Sato O. Impact of angiosome on treatment of diabetic ischaemic foot with paramalleolar bypass.J Jpn Coll Angiol. 2010; 50: 687-691Google Scholar2010JapanRetrospective case series66 (61)BypassNot specifiedMedian, 316 ± 297 (DR) 381 ± 312 (IR) daysComplete wound healing, time to wound healing, major amputationAlexandrescu - SAVES21Alexandrescu V. Ngongang C. Vincent G. Ledent G. Hubermont G. Deep calf veins arterialization for inferior limb preservation in diabetic patients with extended ischaemic wounds, unfit for direct arterial reconstruction: preliminary results according to an angiosome model of perfusion.Cardiovasc Revasc Med. 2011; 12: 10-19Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar2011BelgiumRetrospective case series26 (25)Hybrid – arteriovenous switchUnfit for, or previously failed, conventional treatmentMean, 21.5 (1-62) monthsTechnical success, patency, limb salvage, wound healing, major amputation (1, 6 months then every 6 months)Alexandrescu17Alexandrescu V. Vincent G. Azdad K. Hubermont G. Ledent G. Ngongang C. et al.A reliable approach to diabetic neuroischemic foot wounds: below-the-knee angiosome-oriented angioplasty.J Endovasc Ther. 2011; 18: 376-387Crossref PubMed Scopus (104) Google Scholar2011BelgiumRetrospective case series232 (208)AngioplastyPrimary procedureMean, 38.6 (1-68) monthsTechnical success, survival, freedom from amputation, clinical success, patency, wound healing (12, 24, 36 months)Azuma22Azuma N. Uchida H. Kokubo T. Koya A. Akasaka N. Sasajima T. Factors influencing wound healing of critical ischaemic foot after bypass surgery: is the angiosome important in selecting bypass target artery?.Eur J Vasc Endovasc Surg. 2012; 43: 322-328Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar2012JapanRetrospective case series (consecutive patients)218aData from a subset analysis within larger study. (228)BypassNot specifiedUp to 24 monthsWound healing rate, limb salvage (12, 24 months)Iida24Iida O. Soga Y. Hirano K. Kawasaki D. Suzuki K. Miyashita Y. et al.Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions.J Vasc Surg. 2012; 55: 363-370.e5Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar2012JapanRetrospective case series (consecutive patients)369bForty-six patients included in previous study. (329)AngioplastyNot specifiedMean, 18 ± 16 monthsLimb salvage, death, reintervention rate, amputation-free survival, freedom from major adverse limb events, freedom from major amputationSoderstrom19Soderstrom M. Alback A. Biancari F. Lappalainen K. Lepantalo M. Venermo M. Angiosome-targeted infrapopliteal endovascular revascularization for treatment of diabetic foot ulcers.J Vasc Surg. 2013; 57: 427-435Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar2013FinlandRetrospective case series (consecutive patients)250 (226)AngioplastyPrimaryUp to 1 yearUlcer healing rate, limb salvage, survival, amputation-free survival, reinterventions (1 month then every 1-3 months)Kabra27Kabra A. Suresh K.R. Vivekanand V. Vishnu M. Sumanth R. Nekkanti M. Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia.J Vasc Surg. 2013; 57: 44-49Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar2013IndiaProspective case series64Both/hybridNot specifiedUp to 6 monthsUlcer healing, major amputation, death (1, 3, 6 months)Fossaceca26Fossaceca R. Guzzardi G. Cerini P. Cusaro C. Stecco A. Parziale G. et al.Endovascular treatment of diabetic foot in a selected population of patients with below-the-knee disease: is the angiosome model effective?.Cardiovasc Intervent Radiol. 2013; 36: 637-644Crossref PubMed Scopus (44) Google Scholar2013ItalyRetrospective case series201 (201)AngioplastyNot specifiedMedian 17.5 ± 12 monthsTechnical success, partial ulcer healing, complete ulcer healing, restenosis, major amputation, minor amputation, limb salvage, TcPO2 (1, 6, 12 months then every 6 months)a Data from a subset analysis within larger study.b Forty-six patients included in previous study. Open table in a new tab Patient comorbidities were included in all studies (Table II). Patients with diabetes were included in all studies and were predominant in nine papers (>80% patients with diabetes). Not all studies applied measures to account for confounding factors. Five of 11 studies included information on the topographical location of disease. The most common site of tissue loss was the forefoot, including toes. Clinical assessment of ulceration was recorded by eight studies using validated systems such as the Rutherford system (in seven studies), Wagner scale (in two studies), the University of Texas Wound Classification System (in one study), and the Fontaine Stage (in one study). Preprocedural measures of perfusion were specified in eight studies, including toe pressure, ankle-brachial pressure index (ABPI), skin perfusion pressure (SPP), or transcutaneous oximetry (tcPO2). The presence of neuropathy was documented in two studies, and presence of infection was documented in four studies, but the definition of these terms was unclear in one study (Table II).Table IIPatient comorbiditiesFirst author (year of publication)Number of patientsMaleDiabetesESRDSmokerCoronary artery diseaseHypertensionPresence of neuropathySeverity of woundsIndication for intervention (all patients with non-healing ulceration)Presence of infectionNeville (2009)25Neville R.F. Attinger C.E. Bulan E.J. Ducic I. Thomassen M. Sidawy A.N. Revascularization of a specific angiosome for limb salvage: does the target artery matter?.Ann Vasc Surg. 2009; 23: 367-373Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar4854%87%52%36%29%39%Not specifiedNot specifiedABPI <0.3, monophasic waveforms, TcO2 index 2 weeks duration, ABPI <0.5, monophasic waveforms, toe pressure <50 mm Hg, lack of pedal pulses53% (according to CDC/NHSN surveillance definition)Iida (2010)18Iida O. Nanto S. Uematsu M. Ikeoka K. Okamoto S. Dohi T. et al.Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia.Catheter Cardiovasc Interv. 2010; 75: 830-836PubMed Google Scholar17763%68%54%31%54%82%Not specifiedRutherford 5 (71%) or 6 (29%)Ankle pressure <70 mm Hg, toe pressure <50 mm Hg, SPP <40 mm HgNot specifiedDeguchi (2010)23Deguchi J. Kitaoka T. Yamamoto K. Matsumoto H. Sato O. Impact of angiosome on treatment of diabetic ischaemic foot with paramalleolar bypass.J Jpn Coll Angiol. 2010; 50: 687-691Google Scholar6178%100%59%Not specified28%Not specifiedAlexandrescu (2011) – SAVES21Alexandrescu V. Ngongang C. Vincent G. Ledent G. Hubermont G. Deep calf veins arterialization for inferior limb preservation in diabetic patients with extended ischaemic wounds, unfit for direct arterial reconstruction: preliminary results according to an angiosome model of perfusion.Cardiovasc Revasc Med. 2011; 12: 10-19Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar2572%100%57%Not specified88%Not specified88%Rutherford 5 or 6; Wagner 3-4 (69%, complex 31%)TcPO2 2 cmAzuma (2012)22Azuma N. Uchida H. Kokubo T. Koya A. Akasaka N. Sasajima T. Factors influencing wound healing of critical ischaemic foot after bypass surgery: is the angiosome important in selecting bypass target artery?.Eur J Vasc Endovasc Surg. 2012; 43: 322-328Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar21874%81%50%Not specifiedRutherford 5 (62%), Rutherford 6 (38%)Not specifiedIida (2012)24Iida O. Soga Y. Hirano K. Kawasaki D. Suzuki K. Miyashita Y. et al.Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions.J Vasc Surg. 2012; 55: 363-370.e5Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar32968%73%63%27%58%78%Not specifiedRutherford 5 (73%) or 6 (27%)Toe pressure <50 mm Hg, SPP <40 mm Hg39% on antibioticsSoderstrom (2013)19Soderstrom M. Alback A. Biancari F. Lappalainen K. Lepantalo M. Venermo M. Angiosome-targeted infrapopliteal endovascular revascularization for treatment of diabetic foot ulcers.J Vasc Surg. 2013; 57: 427-435Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar22664%100%39%21%64%76%Not specifiedUTWCS Grade 3 (55%)ABPI mean 0.68, toe pressure mean 38 mm HgUTWCS stage D (39%)Kabra (2013)27Kabra A. Suresh K.R. Vivekanand V. Vishnu M. Sumanth R. Nekkanti M. Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia.J Vasc Surg. 2013; 57: 44-49Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar6483%82%81%16%31%60%Not specifiedRutherford 4 (2%), 5 (84%), 6 (14%)ABPI mean 0.5Not specifiedFossaceca (2013)26Fossaceca R. Guzzardi G. Cerini P. Cusaro C. Stecco A. Parziale G. et al.Endovascular treatment of diabetic foot in a selected population of patients with below-the-knee disease: is the angiosome model effective?.Cardiovasc Intervent Radiol. 2013; 36: 637-644Crossref PubMed Scopus (44) Google Scholar20168%100%7%Not specified32%62%Not specifiedFontaine Stage IV, Rutherford 5 or 6TcPO2 70% caliber reduction, PSV >4 m/s)Not specifiedABPI, Ankle-brachial pressure index; ESRD, end-stage renal disease; CDC/NHSN, Center for Disease Control National Healthcare Safety Network; PSV, peak systolic velocity; UTWCS, University of Texas Wound Classification System. Open table in a new tab ABPI, Ankle-brachial pressure index; ESRD, end-stage renal disease; CDC/NHSN, Center for Disease Control National Healthcare Safety Network; PSV, peak systolic velocity; UTWCS, University of Texas Wound Classification System. TASC II classification of disease severity was documented in four studies (Table III). Some studies considered only those patients with single crural vessel run-off,20Varela C. Acin F. de Haro J. Bleda S. Esparza L. March J.R. The role of foot collateral vessels on ulcer healing and limb salvage after successful endovascular and surgical distal procedures according to an angiosome model.Vasc Endovascular Surg. 2010; 44: 654-660Crossref PubMed Scopus (115) Google Scholar, 27Kabra A. Suresh K.R. Vivekanand V. Vishnu M. Sumanth R. Nekkanti M. Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia.J Vasc Surg. 2013; 57: 44-49Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar one looked specifically at isolated below-the-knee lesions,24Iida O. Soga Y. Hirano K. Kawasaki D. Suzuki K. Miyashita Y. et al.Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions.J Vasc Surg. 2012; 55: 363-370.e5Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar and others at multi-level disease including aorto-iliac lesions.18Iida O. Nanto S. Uematsu M. Ikeoka K. Okamoto S. Dohi T. et al.Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia.Catheter Cardiovasc Interv. 2010; 75: 830-836PubMed Google Scholar The target artery also varied, and this was not reported consistently between studies. The anterior tibial was the artery that most frequently fed the affected angiosome, as reported in three studies. The posteri
Referência(s)