Forget about the angiosome theories Yann Gouëffic, MD, PhD Department of vascular surgery, institut du thorax, Nantes, France
Disclosure of Interest Research grants /Consulting/Honoraria for - Abbott - Bard - Boston Sc - Cook - Hexacath - Medtronic - Spectranetics - Terumo - WL Gore
Patient history Male, 72 y Symptomatology - CLI of the left foot (Rutherford 5) Medical history - Dislipidemia, HTA, active smoking - Peripheral arterial disease - Coronaropathy Duplex scan - Diffuse lesions of femoropopliteal segment Angiography - Femoropoplpiteal thrombosis - No run off
Transmetatarsal amputation of the 1st toe without revascularization
Angiogram
Peroneal artery Posterior tibial artery Angiosome based revascularization Angiosome is an anatomic unit of tissue fed by a source artery and drained by specific veins.
Biancari, Eur J Vasc Endovasc Surg, 2014
A prospective study to evaluate the angiosome concept on the level of microcirculation during BTK interventions. - 30 patients with isolated tibial angioplasty - Macrocirculation was evaluated by measurement of ABI. - Microcirculation was evaluated by a combined method of laser Doppler flowmetry and tissue spectrometry - Measuring points were located over different angiosomes of the index foot; a control probe was placed on the contralateral leg. Conclusions: There is a significant overall improvement in tissue perfusion of the foot immediately after tibial angioplasty. The effect shown was found to be global and was not restricted to certain borders, such as defined by angiosomes. Rother, J Vasc Surg 2016
To investigate factors in patients with CLI and isolated infrapopliteal lesions that adversely affect outcomes of endovascular therapy with or without angiosome-oriented revascularization. - Retrospective multicenter study - 718 consecutive CLI patients - 75% diabetics, 68% hemodialysis, 24% Rutherford 6 - Primary outcome was freedom from MALE - Comparison between direct and indirect angiosome revascularization Conclusion: Limb prognosis was equivalent for direct and indirect endovascular revascularization except in the presence of both diabetes and wound infection. Iida, Eur J Vasc Endovasc Surg, 2013
Wounds were not located only in one angiosome but that, more likely, they affect several angiosomes. In 33% of the patients, there was only one crural artery suitable for revascularization. Indirect revascularization because: - Technical failure to realize direct revascularization (50%) - No attempt because of a long lesion (30%) - No explanation (20%) => vessel providing easier revascularization was selected. Spillerova, Ann Vasc Surg, 2016.
Femoropopliteal recanalization
Long femoropopliteal stenting
Fibullar artery recanalization
Final angiogram
1-month later
Message to take home We forget the angiosome theory: In patients without diabetes (Iida, Eur J Vasc Endovasc Surg, 2013) (In patient without renal failure) Tissue perfusion of the foot immediately after tibial angioplasty is improved globally and is not restricted to certain borders, such as defined by angiosomes (Rother, J Vasc Surg 2016) Several angiosomes are affected in 76% cases (Spillerova, Ann Vasc Surg, 2016) We select the easier vessel to revascularize (time consuming, costly, technical success)
Angio 2D for an intra operative assessment 2D perfusion angiography can help to determine an endpoint for revascularization. Standard digital subtraction angiography 2D perfusion images are obtained by automatic reconstruction with postprocessing software on a dedicated workstation (Philips Medical Systems). The reconstructed images can be evaluated for arrival time, time to peak, wash-in rate, width, area under the curve, and mean transit time. Comparison of the density before and after the interventional procedure is subsequently performed. J Van Den Berg, Endovascular today, 2016