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