Angiosome Concept of Revascularization:

The Evidence or Lack of It

Dr. Saad Alqahtani, MD, FMH, EBIRConsultant & Head of Interventional RadiologyKing Fahad Armed Forces Hospital, Southern Region Saudi Arabia

Angiosomes

Concept introduced in 1987Taylor & Palmer et al. Br J Plast Surg 1987;40:113

3D zones Supplied by specific source arteries Drained by specific veins

Angiosomes

posterior tibial

peroneal

anterior tibial

Background

Medial plantar artery .Medial plantar artery

Dr. Marianne Brodmann, Austria

Healing is more likely after direct revascularization of the correct angiosome !

Angiosome concept helps explain the variability in results of angioplasty for CLI !!

Patent bypass but failed healing in 10-18% Simons et al J Vasc Surg 2010;51:1419-24

Early Findings

Tibial angioplasty Appropriate angiosome treated 83% healed Boundary artery treated 59% healed

Alexandrescu et al. J Endovasc Ther 2008;15:580

Tibial bypass Appropriate angiosome treated 91% healed Boundary artery treated 62% healed

Neville et al. Ann Vasc Surg 2009;23:367

But.. Limb salvage and

amputation free survival didn’t

change

Osamu Lida et. al, Catheterization and cardiovascular interventions, 2010

Kabra et al., J Vasc Surg 2013 3:57:44-9

European J of Vascular and Endovascular Surgery, 2014 [in press]

European J of Vascular and Endovascular Surgery, 2014 [in press]

European J of Vascular and Endovascular Surgery, 2014 [in press]

The quality of the pedal arch did not influence the patency or the amputation-free survival rates. However, the rates for healing and time to healing were directly influenced by the quality of the pedal arch rather than the angiosome revascularized.

Rashid et al., J Vasc Surg. 2013 May;57(5):1219-26

No differences were observed between obtaining a single patent tibial vessel versus more than one tibial vessel.

Indirect revascularization of the ulcer through arterial-arterial connections provided similar results than those obtained after direct revascularization via its specific angiosome tibial artery.

Francisco Acin et al., Int J Vasc Med. 2014;2014:270539

Draw backs

Small study numbers Predominantly retrospective data Use of historical controls Lack of angiographic data. Lack of any information regarding

co-intervention

The heterogeneity of data, patient characteristics, and lack of standardized definitions

Concept of indirect revascularization through collaterals (IRc) and its effect on outcomes is poorly studied

Comorbidities (confounders):

Renal impairment, CAD,… Smoking Severity of the foot ulcers Delay of treatment

What else ?....

Good quality RCTs

High No. of patients Standardization of distribution,

dimensions, & severity of lesions, Angiographic data Subgroup analysis Important outcomes

What do we need ?....

Revascularization of the vessel specifically related to the ulcer or indirectly-related through collateral vessels

Recommendations

It is mandatory to obtain a direct straight line to the foot, even if the injured angiosome is not anatomically fed because this circumstance improves the results of the revascularization significantly

Recommendations

Treat the Whole not the Hole

Any benefit of revascularization can be lost if subsequent appropriate podiatric care is not applied

Thank youThank you