Purpose To evaluate the clinical benefit in wound healing and limb preservation after primary below-the-knee angioplasty guided by an angiosome model of perfusion in diabetic patients with neuroischemic foot ulcers. Methods From September 2001 to April 2010, 232 limb-threatening neuroischemic wounds in 208 diabetic patients (147 men; mean age 74.3 years, range 42–97) were treated by below-the-knee endoluminal and/or subintimal angioplasty. There were 19 (8%) TASC II type B, 80 (34%) type C, and 133 (57%) type D infrapopliteal lesions. Patients treated prior to 2005 when the angiosome-targeted revascularization protocol was introduced (89 limbs, group 1) were compared to 134 limbs treated subsequently according to the angiosome model (group 2). The angiosome-oriented group 2 included 25% procedures focusing on the anterior tibial and dorsalis pedis arteries, 68% on the posterior tibial and plantar vessels, and 7% on the peroneal arteries. Results The global technical success was 80% (187/232): 82% in group 1 and 79% in group 2. The cumulative patient survival rates were 90%, 78%, and 65% in group 1 and 93%, 82%, and 71% in group 2 at 12, 24, and 36 months, respectively (p=0.545). At the same time points, the freedom from amputation rates were 84%, 79%, and 79% in group 1 versus 90%, 89%, and 89% in group 2 (p=0.035). Clinical success rates were 76%, 68%, 68% in the group 1 and 85%, 79%, and 79% in group 2 (p=0.025). Primary and secondary patency rates did not differ between groups (p=0.813 and p=0.511). Patients in group 2 treated with angiosome-targeted revascularization had significantly better wound healing (p<0.018) and limb preservation (p<0.030). Conclusion Below-the-knee first-line angioplasty guided by an angiosome model may prove beneficial in terms of better wound healing of diabetic foot ulcers and subsequent limb salvage. Further technical improvements and large comparative studies are necessary to support these observations.

Purpose: To evaluate the technical and clinical outcomes of primary subintimal (SA) and endoluminal angioplasty (EA) guided by an angiosome model of revascularization in diabetic patients with critical limb ischemia (CLI) and Wagner grade 1–4 foot ulcers. Methods: A retrospective review was undertaken of 98 diabetic CLI patients (68 men; mean age 72.8 years, range 46–94) who presented to our institution from January 2005 to January 2008 for treatment of Wagner grade 1–4 foot ulcers involving 124 limbs. Following the angiosome model of perfusion in the foot and ankle, the target arterial lesions in the 124 limbs were treated with 80 (64%) associated SA and EA procedures, 21 (17%) multilevel EAs, and 23 (18%) single SA techniques. Results: Initial technical success was achieved in 102 (82%) interventions: 82/103 SAs and 20/21 of the EAs. The 30-day survival rate was 98% (1 fatal myocardial infarction). The cumulative rates of primary and secondary patency, limb salvage, and clinical success were: 57%±4%, 71%±4%, 91%±3%, and 85%±3% at 12 months and 48%±5%, 61%±4%, 84%±6%, and 73%±6% at 32 months, respectively. Limb salvage appeared to be negatively affected at 3 years by the presence of Wagner grade 3–4 lesions (p<0.0002), the bedridden condition of patients (p<0.0001), end-stage renal disease (p<0.0001), left ventricular dysfunction (p<0.0001), and peripheral neuropathy (p=0.023). Using the angiosome approach, complete healing of ulcers with or without minor amputation was seen in 79% (98/124 limbs), while 62 of 70 Wagner grade 1–2 and 36 of 54 Wagner 3–4 foot lesions healed in the first 1 to 3 months after revascularization. Conclusion: Targeted primary angioplasty following the angiosome model could be an effective therapeutic method in the ulcer healing process. However, beyond appropriate revascularization, aggressive control of concurrent risk factors in diabetic wound healing probably plays an equally relevant role.

The angiosome concept delineates the human body into three-dimensional blocks of tissue fed by specific arterial and venous sources named “angiosomes.” Adjacent angiosomes are connected by a vast compensatory collateral web, or “choke vessels.” This concept may provide new information applicable to improving targeted revascularization of ischemic tissue lesions. A few dedicated studies available seem to favor this strategy, as encouraging ulcer healing and limb preservation are reported in connection with both bypass and endovascular techniques based on these principles. The theory on the angiosome model of revascularization (AMV) may help the clinician to better refine vessel selection, vascular access, and specific strategies in the revascularization of critically ischemic legs with tissue lesions. Specific applications of angiosome-guided revascularization were recently suggested for patients with diabetes or renal insufficiency, with ischemic tissue lesions of the lower limb, and extended large- and medium-size collateral network decay. For these cases, the concept may allow deliberate arterial reconstruction following individual wound topographies in specific ischemic areas, although deprived from “rescue-vessel” supply. The AMV theory may contribute to a shift in common reperfusion options. However, the data available is suggestive and does not provide strong evidence as factors such as case mix and the severity of ischemia are unsatisfactorily controlled. At present, the evidence is scarce as to the effect of the severity of the arterial disease. In all comparisons, the groups treated are likely to be dissimilar and mismatched. The angiosome concept is postulated to be valid especially in diabetics, whose ischemic lesions tend to heal worse than those of non-diabetics.

Peer reviewed article authored by (Alexandrescu V, Hubermont G). Read article or submit your manuscript for publishing.