Primary infragenicular angioplasty for diabetic neuroischemic foot ulcers following the angiosome distribution: a new paradigm for the vascular interventionist?
Vlad Alexandrescu, Gerard Hubermont, Vlad Alexandrescu, Gerard Hubermont
Abstract
The angiosome principle was first described by Jan Taylor in 1987 in the plastic reconstructive surgery field, providing useful information on the vascular anatomy of the human body. Specifically concerning foot and ankle pathology, it may help the clinician to select better vascular access and specific strategies for revascularization. This knowledge may be particularly beneficial when treating diabetic neuroischemic foot wounds associated with particularly aggressive atherosclerotic disease and a poor collateral circulation. The implementation of angiosome-based strategies in diabetic infragenicular vascular reconstruction may afford encouraging wound healing and limb preservation rates using both bypass and endovascular techniques. The minimal invasiveness of these novel strategies enables us to perform more specific and more distal tibial and/or foot arterial reconstructions, in one or multiple targeted vessels. This paper reviews the available literature on this revascularization strategy and focuses on the potential benefit of angiosome-guided primary angioplasty for diabetic ischemic foot ulcers.
Keywords: angioplasty; angiosomes; critical limb ischemia; diabetic foot; limb salvage.
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References
- Norgreen L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the management of peripheral arterial disease (TASC II) Eur J Vasc Endovasc Surg. 2007;33(Suppl 1):S32–S55.
- Blevins WA, Schneider PA. Endovascular management of critical limb ischemia. Eur J Vasc Endovasc Surg. 2010;39:756–761.
- Conrad MF, Kang J, Cambria RP, et al. Infrapopliteal balloon angioplasty for the treatment of chronic occlusive disease. J Vasc Surg. 2009;50:799–805.
- Romiti M, Albers M, Brochado-Neto FC, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg. 2008;47:975–981.
- Adam DJ, Beard JD, Cleveland T, et al. BASIL trial participants. Bypass versus angioplasty in severe ischemia of the leg (BASIL): Multicentre, randomized controlled trial. Lancet. 2005;366:1925–1934.
- Markose G, Bolia A. Below the knee angioplasty among diabetic patients. J Cardiovasc Surg (Torino) 2009;50:323–329.
- Faglia E, Mantero M, Caminiti M, et al. Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischemic diabetic foot ulcers: Clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med. 2002;252:225–232.
- Simms M. The Foot in Diabetes. 4th ed. Chichester, UK: J Wiley and Sons Ltd; 2007. Peripheral vascular disease and reconstruction.
- Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: Experimental studies and clinical applications. Br J Plast Surg. 1987;40:113–141.
- Attinger CE, Cooper P, Blume P, et al. The safest surgical incision and amputations applying the angiosomes principle and using the Doppler to assess the arterial-arterial connections of the foot and ankle. Foot Ankle Clin North Am. 2001;6:745–801.
- Attinger CE, Evans KK, Bulan E, et al. Angiosomes of the foot and ankle and clinical implications for limb salvage: Reconstruction, incisions and revascularization. Plast Reconstr Surg. 2006;117(7 Suppl):261S–293S.
- Taylor GI, Pan WR. Angiosomes of the leg: Anatomic study and clinical implications. Plast Reconstr Surg. 1997;4:183–198.
- Attinger CE, Evans KK, Mesbahi A. Diabetic Foot, Lower Extremity Arterial Disease and Limb Salvage. Philadelphia, PA: Lippincott Williams and Wilkins; 2006. Angiosomes of the foot and angiosome-dependent healing.
- Attinger CE, Cooper P, Blume P. Vascular anatomy of the foot and ankle. Op Tech Plast Reconstr Surg. 1997;4:183–198.
- Neville RF, Attinger CE, Bulan EJ, et al. Revascularization of a specific angiosome for limb salvage: Does the target artery matter? Ann Vasc Surg. 2009;23:367–373.
- Setacci C, De Donato G, Setacci F, et al. Ischemic foot: Definition, etiology and angiosome concept. J Cardiovasc Surg (Torino) 2010;51:223–231.
- Alexandrescu V, Hubermont G, Philips Y, et al. Selective 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;15:580–593.
- Iida O, Nanto S, Uematsu M, et al. Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia. Catheter Cardiovasc Interv. 2010;75:830–836.
- Varela C, Aci NF, Haro JD, et al. 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 Endovasc Surg. 2010;44:654–660.
- Boulton AJM, Armstrong DG. Clinical Diabetes, Translating Research into Practice. Philadelphia, PA: Saunders Elsevier; 2006. The diabetic foot.
- O’Neal LW. Levin and O’Neal’s The Diabetic Foot. Philadelphia, PA: Mosby Elsevier; 2008. Surgical pathology of the foot and clinicopathologic correlations.
- Clemens MW, Attinger CE. Angiosomes and wound care in the diabetic foot. Foot Ankle Clin. 2010;15:439–464.
- Zhu YQ, Zhao JG, Liu F, et al. Subintimal angioplasty for below-the-ankle arterial occlusions in diabetic patients with chronic critical limb ischemia. J Endovasc Ther. 2009;16:604–612.
- Bazan HA. Think of the angiosome concept when revascularizing the patient with critical limb ischemia. Catheter Cardiovasc Interv. 2010;75:837.
- Irvin CL, Guzman RJ. Matrix metalloproteinases in medial arterial calcification: Potential mechanisms and actions. Vascular. 2009;17(Suppl 1):S40–S44.
- Alexandrescu V. Below-the-ankle subintimal angioplasty: How far can we push this application for lower limb preservation in diabetic patients? J Endovasc Ther. 2009;16:617–618.
- Alexandrescu 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;12:10–19.
- Norgren L, Hiatt WR, Dormandy JA, et al. The next 10 years in the management of peripheral artery disease: Perspectives from the PAD 2009 conference. Eur J Vasc Endovasc Surg. 2010;40:375–380.
- Edmonds M. A natural history and framework for managing diabetic foot ulcers. Br J Nurs. 2008;17:S24–S29.
- Lyden SP, Smouse HB. TASC II and the endovascular management of infrainguinal disease. J Endovasc Ther. 2009;16(Suppl II):5–18.
- Ihnat DM, Mills JL. Current assessment of endovascular therapy for infrainguinal arterial occlusive disease in patients with diabetes. J Vasc Surg. 2010;52:92S–95S.
- Alexandrescu V, Vincent G, Azdad K, et al. A reliable approach to diabetic neuroischemic foot wounds: Below-the-knee angiosome-oriented angioplasty. J Endovasc Ther. 2011;18:376–387.
- O’Brien-Irr MS, Dosluoglu HH, Harris L, et al. Outcomes after endovascular intervention for chronic critical limb ischemia. J Vasc Surg. 2011;53:1575–1581.
- Mustapha JA, Heaney CM. A new approach to diagnosing and treating CLI. Endovasc Today. 2010;9:41–50.
- Apelqvist J, Elgzyri T, Larsson J, et al. Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients. J Vasc Surg. 2011;53:1582–1588.
- Radford K, Chipchase S, Jeffcoate W. The Foot in Diabetes. 4th ed. Chichester, UK: J Wiley and Sons Ltd; 2007. Education in the management of the foot in diabètes.
Source: PubMed