A systematic review and meta-analysis of endovascular angiosomal revascularization in the setting of collateral vessels

Kim, Kevin G.; Meshkin, Dean H.; Tirrell, Abigail R.; Bekeny, Jenna C.; Tefera, Eshetu; Fan, Kenneth L.; Akbari, Cameron M.; Evans, Karen K.

doi:10.1016/j.jvs.2021.04.026

Cited by 6 publications

(5 citation statements)

References 44 publications

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“…[20][21][22] In a meta-analysis on the angiosome concept and the importance of collaterals, with over 4000 endovascular revascularizations, the overall wound healing rates were significantly higher for direct revascularization than for indirect revascularization, but no difference was seen between direct revascularization and indirect revascularization with significant collaterals. 22 Leg salvage was superior in the DR group, but it was significantly better in IR patients with collaterals than in IR patients without collaterals. Again, the outcomes in these retrospective clinical trials are in line with our findings on perfusion increase after revascularization.…”

Section: Discussionmentioning

confidence: 99%

Perfusion increase in foot angiosomes: Comparison between direct and indirect revascularization of crural arteries

Venermo,

Settembre

2024

Scand J Surg

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Background and aims: In retrospective studies, wound healing and leg salvage have been better if revascularization is targeted to the crural artery supplying arterial flow to the wound angiosome. No data exist on how revascularization changes the blood flow in foot angiosomes. The aim of this study was to evaluate the change in perfusion after infrapopliteal artery revascularization in all foot angiosomes and to compare directly revascularized (DR) angiosomes to the indirectly revascularized (IR) angiosomes. Methods: In this prospective study, foot perfusion was measured with indocyanine green fluorescence imaging (ICG-FI) before and after either surgical or endovascular below-knee revascularization. According to angiograms, we divided the foot angiosomes into DR and IR angiosomes. Furthermore, in a subanalysis, the IR angiosomes were graded as IR_Coll+ angiosomes if there were strong collaterals arising from the artery which was revascularized, and as IR_Coll– angiosomes if strong collaterals were not seen. Results: A total of 72 feet (28 bypass, 44 endovascular revascularizations) and 282 angiosomes were analyzed. Surgical and endovascular revascularization increased perfusion significantly in both DR and IR angiosomes. After bypass surgery, the increase in DR angiosomes was 55 U and 53 U in IR angiosomes; there were no significant difference in the perfusion increase between IR and DR angiosomes. After endovascular revascularization, perfusion increased significantly more, 40 U, in DR angiosomes compared to 26 U in IR angiosomes (p < 0.05). In the subanalysis of IR angiosomes, perfusion increased significantly after surgical bypass regardless of whether strong collaterals were present or not. After endovascular revascularization, however, a significant perfusion increase was noted in the IR_Coll+ but not in the IR_Coll− subgroup. Conclusion: Open revascularization increased perfusion equally in DR and IR angiosomes, whereas endovascular revascularization increased perfusion significantly more in DR than in IR angiosomes. Strong collateral network may help increase perfusion in IR angiosomes.

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Section: Discussionmentioning

confidence: 99%

Perfusion increase in foot angiosomes: Comparison between direct and indirect revascularization of crural arteries

Venermo,

Settembre

2024

Scand J Surg

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“…4 A recent meta-analysis of 21 studies found that angiosome-directed revascularization improved wound healing rates in comparison with indirect revascularization; additionally, it also improved limb salvage rates. 16 Achieving direct flow to the site of ulceration/gangrene is more important for successful limb salvage than the number of patent runoff vessels in the clinical settings. 17 The novel IM classification based on the concept of TAP may be more reliable than the number of BTA runoff vessels on predicting clinical outcomes in patients with CLTI.…”

Section: Discussionmentioning

confidence: 99%

Effects of Infra-malleolar Status According to Global Limb Anatomic Staging System on Clinical Outcomes in Patients With Chronic Limb-Threatening Ischemia

et al. 2022

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The global vascular guideline proposed a novel anatomical classification of infra-malleolar (IM) arterial lesions. We aimed to investigate the association of IM classification with clinical outcomes in patients with chronic limb-threatening ischemia (CLTI) due to isolated infrapopliteal (IP) lesions. We retrospectively analyzed 509 limbs with tissue loss in 357 patients due to isolated IP lesions who underwent endovascular therapy (EVT) between April 2010 and December 2018. The primary outcome was 1-year wound healing rate. The association of patient and anatomic characteristics with non-healing was evaluated using Cox proportional hazards regression analysis. The 1-year cumulative wound healing rate was 59.7%. Multivariable analysis demonstrated that IM grade 2 (hazard ratio [HR], 1.41; P = .044), non-ambulatory status (HR, 1.49; P = .008), hemodialysis (HR, 1.37; P = .020), left ventricular ejection fraction < 50% (HR, 1.72; P = .030), and wound, ischemia, and foot infection (WIfI) classification 4 (HR, 1.33; P = .032) were significantly associated with non-healing, whereas no below-the-ankle (BTA), below-the-knee (BTK) runoff, and Global Limb Anatomic Staging System (GLASS) IP grade had no statistically significant association with non-healing. Global Limb Anatomic Staging System IM grade 2 was an independent risk factor for wound healing in patients who underwent EVT with CLTI due to isolated IP disease.

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“…Analysis of outcome data for DR, IR and IRc (when reported) and endovascular and open revascularisation was conducted descriptively. Previous meta‐analysis for DR and IR has demonstrated excessive heterogeneity in a similar data set for the primary outcome of healing 25 . Variable reporting of IR and IRc, lack of randomisation of participants into interventions of both studies of IR and DR and studies of endovascular and open revascularisation, and the retrospective nature of the majority of available evidence for all these interventions were considered by the authors of this review to preclude pooled analyses of available data.…”

Section: Methodsmentioning

confidence: 99%

Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review

Chuter

Schaper

Mills

et al. 2023

Diabetes Metabolism Res

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IntroductionPeripheral artery disease (PAD) is associated with an increased likelihood of delayed or non‐healing of a diabetes‐related foot ulcer, gangrene, and amputation. The selection of the most effective surgical technique for revascularisation of the lower limb in this population is challenging and there is a lack of conclusive evidence to support the choice of intervention. This systematic review aimed to determine, in people with diabetes and tissue loss, if direct revascularisation is superior to indirect revascularisation and if endovascular revascularisation is superior to open revascularisation for the outcomes of wound healing, minor or major amputation, and adverse events including mortality.MethodsTitle and abstract searches of Medline, Embase, PubMed, and EBSCO were conducted from 1980 to 30th November 2022. Cohort and case‐control studies and randomised controlled trials reporting comparative outcomes of direct (angiosome) revascularisation (DR) and indirect revascularisation (IR) or the comparative outcomes of endovascular revascularisation and open or hybrid revascularisation for the outcomes of healing, minor amputation, and major amputation in people with diabetes, PAD and tissue loss (including foot ulcer and/or gangrene) were eligible. Methodological quality was assessed using the Cochrane risk‐of‐bias tool for randomised trials, the ROBINS‐I tool for non‐randomised studies, and Newcastle‐Ottawa Scale for observational and cohort studies where details regarding the allocation to intervention groups were not provided.ResultsFrom a total 7086 abstracts retrieved, 26 studies met the inclusion criteria for the comparison of direct angiosome revascularisation (DR) and indirect revascularisation (IR), and 11 studies met the inclusion criteria for the comparison of endovascular and open revascularisation. One study was included in both comparisons. Of the included studies, 35 were observational (31 retrospective and 4 prospective cohorts) and 1 was a randomised controlled trial. Cohort study quality was variable and generally low, with common sources of bias related to heterogeneous participant populations and interventions and lack of reporting of or adjusting for confounding factors. The randomised controlled trial had a low risk of bias. For studies of DR and IR, results were variable, and it is uncertain if one technique is superior to the other for healing, prevention of minor or major amputation, or mortality. However, the majority of studies reported that a greater proportion of participants receiving DR healed compared with IR, and that IR with collaterals may have similar outcomes to DR for wound healing. For patients with diabetes, infrainguinal PAD, and an adequate great saphenous vein available for use as a bypass conduit who were deemed suitable for either surgical procedure, an open revascularisation first approach was superior to endovascular therapy to prevent a major adverse limb event or death (Hazard Ratio: 0.72; 95% CI 0.61–0.86). For other studies of open and endovascular approaches, there was generally no difference in outcomes between the interventions.ConclusionsThe majority of available evidence for the effectiveness of DR and IR and open and endovascular revascularisation for wound healing and prevention of minor and major amputation and adverse events including mortality in people with diabetes, PAD and tissue loss is inconclusive, and the certainty of evidence is very low. Data from one high quality randomised controlled trial supports the use of open over endovascular revascularisation to prevent a major limb event and death in people with diabetes, infrainguinal disease and tissue loss who have an adequate great saphenous vein available and who are deemed suitable for either approach.

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A systematic review and meta-analysis of endovascular angiosomal revascularization in the setting of collateral vessels

Cited by 6 publications

References 44 publications

Perfusion increase in foot angiosomes: Comparison between direct and indirect revascularization of crural arteries

Perfusion increase in foot angiosomes: Comparison between direct and indirect revascularization of crural arteries

Effects of Infra-malleolar Status According to Global Limb Anatomic Staging System on Clinical Outcomes in Patients With Chronic Limb-Threatening Ischemia

Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review

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