THERE IS NO PROOF FOR THE ANGIOSOME CONCEPT
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1 THERE IS NO PROOF FOR THE ANGIOSOME CONCEPT Peter Huppert Professor of Radiology and Neuroradiology Department of Radiology, Neuroradiology and Nuclear Medicine Klinikum Darmstadt Academic Teaching Hospital University of Frankfurt and Mannheim/Heidelberg Germany Certified Vascular Center
2 Disclosures Speaker name: Huppert, Peter I have the following potential conflicts of interest to report: X Consulting: - Boston Scientific - Abbott Vascular - Johnson&Johnson/Cordis - Merritt Medical
3 Concept of Angiosomes Taylor GI, Pan WR (1998) Taylor GI, Palmer JH (1987) Angiosomes threedimensional composite vascular territories that span between the skin and bone......supplied by named source arteries studies at 16 cadaver legs; no description of any preexisting vascular occlusion
4 Concept of Angiosome related Revascularization In CLI patients, direct RV of angiosome-related arteries is more effected than indirect RV of another artery. Limitations Anatomical rationale Proof of concept
5 Multilevel System of Anastomoses between 3 Major Source Arteries Attinger CE et al Plast Reconstr Surg 117 (Suppl.) 261S-293S Anastomoses between distal source arteries - R. perforans ant. R. mall. lat. (PTA ATA) - Rr. transversi (PA - PTA) - DPA A. plant. lat. (ATA - PTA) - R. mall med, post./ant. (PTA DPA) - Rr. calcanei (AP ATP) Intermetatarsal perforators (ADP ATP) Cross anastomoses at DI (ADP ATP) Subdermal plantar arteriolar network Choke-Vessel
6 Breakdown of Angiosome Borders Activation of multilevel anastomoses between major source arteries in case of occlusions Collateral circulation to adjacent angiosomes Modifications due to occlusions of distal source arteries Considerable overlap of major source artery related territories at digiti and heel
7 Major and distal Source Arteries Major source arteries Distal source arteries Angiosomes Anterior tibial artery Dorsal pedal artery Dorsum pedis, digiti Posterior tibial artery Medial plantar artery Plantar medial, digiti Lateral plantar artery Plantar lateral, digiti Medial calcaneal branch heel Peroneal artery Lateral calcaneal branch heel Anterior perforating branch Lateral malleolar region
8 Impact of distal Source Arteries Dorsal pedal artery Lateral plantar artery Medial calcaneal branch
9 Angiosome-oriented RV Lesion location Heel Plantar region Lateral malleolar region Dorsum pedis Digiti Major source artery PA, PTA PTA PA ATA/DPA PTA, ATA Depending on status of distal source arteries: dorsal pedal, lateral/medial plantar, calcaneal branches
10 Limitations of Studies demonstrating Proof of Concept Definition of direct / indirect RV of lesions at AS borderlines: digiti and heel Exclusion of large lesion involving multiple AS Impact of distal source artery occlusions Consideration of major prognostic risk factors (diabetes, ESRD, Rutherford stage 6) Retrospective study design
11 Study Limitations study design RV Borderline lesions Risk adjust. Clinical success rate DR/IR outcome Neville `09 r op heel no 91/62% 0.5 a - healing Alexandrescu `11 (r) ev n.r. no 89/79% 3 a - limb salvage Azuma `12 r op digiti, heel yes 98/92% 2 a- limb salvage Iida `12 r ev digiti 85% yes 82/68% 18 m- limb salvage Söderström `13 r ev digiti, heel yes 86/77% 1 a - limb salvage 74/74% 1 a - AFS
12 Conclusions Chronic BTK artery occlusions cause activation of multilevel collateral pathways changing strict relations between major source arteries and dependent vascular territories. Atherosclerotic lesions of distal source arteries, large lesions overlapping borderlines of AS and major risk factors of healing strongly modify effects of peripheral RV. AS concept may guide intention to direct RV but is no dogma to ignore benefits of indirect RV.
13 Thank You for Attention!
14 Thank You for Attention!
15 THERE IS NO PROOF FOR THE ANGIOSOME CONCEPT Peter Huppert Professor of Radiology and Neuroradiology Department of Radiology, Neuroradiology and Nuclear Medicine Klinikum Darmstadt Academic Teaching Hospital University of Frankfurt and Mannheim/Heidelberg Germany Certified Vascular Center
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