When is the angiosome concept the right concept and how to traslate into practice

Antonio Micari GVM Care and Research Cotgnola and Palermo

Angiosomes

“Three-dimensional blocks of tissue fed by source arteries”

Ian Taylor1

1 The vascular territories (angiosomes) of the body: Experimental studies and clinical applications, Taylor, GI and Palmer JH. Br. J. Plast. Surg. 1990;43.

Angiosomes

ANGIOSOMES

• Normal foot circulation is an ANASTOMOTIC System • In DM patients collateral desease led to a “terminal like”

circulation

Wound Related Artery

• 48 patients, 52 non healing ulcers

• Direct revascularisation vs

Indirect revascularisation

• 329 patients, 369 ischaemic limbs

\

• 1268 patients, 1445 procedures

• Overall:

– 1 year primary LS 76%

– 1 year secondary LS 84%

Targets in CLI Revascularization

• Complete Revascularization • Wound Related Artery (Angiosome) • Approachable artery

Revascularization Strategies Affecting CLI

Outcomes

1. The most important factor affecting Limb Salvage is the number of patent

arteries post-PTA [1;2]

1. 1 vessel better than 0

2. 2-3 vessels better than 1

3. Tibials better than peroneal

2. Direct revascularization (distal bypass) of the angiosome specific to the

anatomy of the wound leads to a higher rate of healing and limb salvage [3]

3. Trade-off between driven by 1) procedural time and cost, and 2) technical

access / success in treating the angiosome specific vessel

1. Peregrin et al. PTA of Infrapopliteal Arteries: Long-term Clinical Follow-up and Analysis of Factors Influencing Clinical Outcome Cardiovasc

Intervent Radiol (2010) 33:720–725

2. Faglia et al. When is a technically successful peripheral angioplasty effective in preventing above-the-ankle amputation in diabetic patients with

critical limb ischaemia Diabet Med. 2007 Aug;24(8):823-9

3. Neville et al. Revascularization of a Specific Angiosome for Limb Salvage: Does the Target Artery Matter? Ann Vasc Surg 2009; 23: 367-373

Targets in BTK PTA: complete vs. selected revascularization

Courtesy of R. Ferraresi

CLI Revascularization

Complete Revascularization

Rutherford VI and planned TMA needs more than one Angiosome

Wound Related Artery (Angiosome)

Well demarcated and isolated Toes, Heel, Dorsum foot wounds

Angio Team & Foot Team Collaboration and

planning

CLI Revascularization

Failed recanalization by antegrade way

Collateral circulation to plantar artery

(injection through the balloon)

Passage of guidewire through collateral vessel in

posterior tibial artery by retrograde way and

dilatation of the occlusion

Passage of new guidewire by antegrade way and

POBA

Final result

Wound Related Artery Surrogate

flexible balloons

Wound Related Artery Surrogate

Wound Related Artery Surrogate

CONCLUSIONS

• Angiosome Revascularizzation is better than Indirect;

• There is a trade off between angiosome revasc and time/cost/ complicances

• Huge wounds and TMA involve more than one angiosome: complete revascularization should be indicated;

CONCLUSIONS

• Angiosome Revascularizzation is better than Indirect;

• There is a trade off between angiosome revasc and time/cost/ complicances

• Huge wounds and TMA involve more than one angiosome: complete revascularization should be indicated;