Commentary: Myths and Proofs of Angiosome Applications in CLI: Where Do We Stand?

Alexandrescu, Vlad

doi:10.1583/14-4692c.1

Cited by 18 publications

(54 citation statements)

References 45 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…As previously described [23,24], the foot angiosomes are 3-D dynamic and continuously interacting structures [30]. Although their primary anatomical distribution seems accurately reproduced in more than 90% of subjects (owing 6-9% eventual anatomival variants) [23,24,26,91], their interconnections ("choke vessels") are yet submitted to continuous changes, according to each type of CLI pathology [72,[95][96][97][98].…”

Section: The "Angiosome Concept" In Ischemic Wound Healing: a Succincmentioning

confidence: 90%

“…These vascular territories are closely interconnected by numerous arterial-arterial communicants [23,24], whose caliber and density are strongly influenced by the age of patients, by each region's anatomy and by the manifest arterial disease triggering CLI [24,35,72,[96][97][98]. Every individual collateral system essentially assists blood supply between neighboring angiosomes.…”

Section: The "Angiosome Concept" In Ischemic Wound Healing: a Succincmentioning

confidence: 99%

“…Optimal wound-targeted revascularization probably means correct angiosome-related anatomical evaluation associated with individual collateral-related pathophysiological judgment for each CLI presentation [30]. In young subjects with unaltered collateral network possible post-traumatic or ischemic injuries activate unmitigated "choke-vessels" that warrant (at some point) effective compensatory blood pressure between adjacent angiosomes [24,39,96,97]. Atherosclerotic, inflammatory, or local thrombotic conditions may alter this unique natural compensatory system.…”

Section: The "Angiosome Concept" In Ischemic Wound Healing: a Succincmentioning

confidence: 99%

“…Assessing and treating ischemic wounds in the light of the angiosome theory imposes a flexible reflection upon how utilizing the remnant arterial-arterial connections (Figures 2 and 3) at best flow benefit for the patient [88,97].…”

Section: The "Angiosome Concept" In Ischemic Wound Healing: a Succincmentioning

confidence: 99%

See 3 more Smart Citations

Ischemic Ulcer Healing: Does Appropriate Flow Reconstruction Stand for All That We Need?

Alexandrescu¹,

Triffaux²

2016

Wound Healing - New Insights Into Ancient Challenges

Self Cite

View full text Add to dashboard Cite

During the recent decades, soaring progresses in vascular disease knowledge, particularly in critical limb ischemia (CLI) treatment, enhanced novel diagnostic and interventional strategies with high serviceableness in patient's selection, arterial recanalization, and dedicated ischemic ulcer follow-up. However, despite undeniable advances in medical technology and clinical judgment, limb salvage, the ambulation recovery, and patient's survival seem only scarcely affected in this heterogeneous CLI group, particularly concerning the diabetic and renal patients. Innovative strategies such as "end artery occlusive disease" treatment or "wound-targeted revascularization" were equally proposed by following the angiosomal anatomical distribution associating individual foot collateral assessment in a unified macro-and micro-circulatory judgment. However, despite encouraging clinical results, prospective evidence still lacks on this concern. It also appears that specific wounds could not always stand for the lowest perfusion areas according to current CLI criteria, since severe neuropathy, inflammatory swelling, local infection, and skin trauma may add complementary hindrances to tissue viability.The present chapter endeavor to summarize main available treatment principles for ischemic ulcer recovery that every modern practitioner eventually disposes in an updated contemporary view."

show abstract

Section: The "Angiosome Concept" In Ischemic Wound Healing: a Succincmentioning

confidence: 90%

Section: The "Angiosome Concept" In Ischemic Wound Healing: a Succincmentioning

confidence: 99%

Section: The "Angiosome Concept" In Ischemic Wound Healing: a Succincmentioning

confidence: 99%

Section: The "Angiosome Concept" In Ischemic Wound Healing: a Succincmentioning

confidence: 99%

See 2 more Smart Citations

Ischemic Ulcer Healing: Does Appropriate Flow Reconstruction Stand for All That We Need?

Alexandrescu¹,

Triffaux²

2016

Wound Healing - New Insights Into Ancient Challenges

Self Cite

View full text Add to dashboard Cite

show abstract

“…However, this angiographic angiosome may not be appropriate to address the local tissue perfusion that cannot be visualized by angiography, especially in patients with DM. 11 Furthermore, assessment of the effectiveness of the vascular treatment still mostly relies primarily on the toe pressure or transcutaneous oxygen tension (TcPO 2 ), which may not be a sensitive indicator of the perfusion in the specific area where the wound is located. 9,10 In addition to the observation that toe pressure often fails to assess the specific region at risk (ie, the wound), toe pressures cannot be obtained on patients with a toe amputation.…”

mentioning

confidence: 99%

Oximetric angiosome imaging in diabetic feet

Zheng

Muccigrosso

Zhang

et al. 2016

Magnetic Resonance Imaging

View full text Add to dashboard Cite

Purpose-To develop a noncontrast oximetric angiosome imaging approach to assess skeletal muscle oxygenation in diabetic feet.Materials and Methods-In four healthy and five subjects with diabetes, the feasibility of foot oximetry was examined using a 3T clinical magnetic resonance imaging (MRI) scanner. The subjects' feet were scanned at rest and during a toe-flexion isometric exercise. The oxygen extraction fraction of skeletal muscle was measured using a susceptibility-based MRI method. Our newly developed MR foot oximetric angiosome model was compared with the traditional angiosome model in the assessment of the distribution of oxygen extraction fraction.Results-Using the traditional angiosome during the toe-flexion exercise, the oxygen extraction fraction in the medial foot of healthy subjects increased (4.9 ± 3%) and decreased (−2.7 ± 4.4%) in subjects with diabetes (difference = 7.6%; 95% confidence interval = −13.7 ± 1.4; P = 0.02).Using the oximetric angiosome, the percent difference in the areas of oxygen extraction fraction within the 0.7-1.0 range (expected oxygen extraction fraction during exercise) between rest and exercise was higher in healthy subjects (8 ± 4%) than in subjects with diabetes (4 ± 4%; P = 0.02).Conclusion-This study demonstrates the feasibility of measuring skeletal muscle oxygen extraction fraction in the foot muscle during a toe-flexion isometric exercise. Instead of assessing oxygen extraction fraction in a foot muscle region linked to a supplying artery (traditional angiosome), the foot oximetric angiosome model assesses oxygen extraction fraction by its different levels in all foot muscle regions and thus may be more appropriate for assessing local ischemia in ulcerated diabetic feet.Foot disorders (such as ulceration, infection, and gangrene) are the leading causes of hospitalization in patients with diabetes mellitus (DM). 6 One key prognostic factor that is currently lacking in diabetic foot care is an accurate indicator of the local microvascular bed basal flow (skeletal muscle perfusion) and responsiveness (skeletal muscle oxygenation) to help guide diagnosis and intervention. HHS Public AccessThe angiosome concept, defined by Taylor and Palmer in 1987, 7 has been increasingly incorporated into endovascular procedures to treat patients with foot ulcers. [8][9][10] This angiosome model (called traditional angiosome in this project) divides the foot into three angiosomes: medial plantar, lateral plantar, and calcaneal angiosomes. These angiosomes are supplied by blood flow from medial plantar, lateral plantar, and medial calcaneal arteries, respectively. After identifying the artery responsible for perfusing the angiosome in which the ulcer is located, directed revascularization of that end-artery is undertaken to optimize healing. However, this angiographic angiosome may not be appropriate to address the local tissue perfusion that cannot be visualized by angiography, especially in patients with DM. 11 Furthermore, assessment of the effectiveness of the vascular ...

show abstract

IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes

Hinchliffe

Brownrigg

Apelqvist

et al. 2016

Diabetes Metabolism Res

180

187

View full text Add to dashboard Cite

Recommendations1. Examine a patient with diabetes annually for the presence of peripheral artery disease (PAD); this should include, at a minimum, taking a history and palpating foot pulses. (GRADE strength of recommendation: strong; quality of evidence: low) 2. Evaluate a patient with diabetes and a foot ulcer for the presence of PAD.Determine, as part of this examination, ankle or pedal Doppler arterial waveforms; measure both ankle systolic pressure and systolic ankle brachial index (ABI). (strong; low) 3. We recommend the use of bedside non-invasive tests to exclude PAD. No single modality has been shown to be optimal. Measuring ABI (with <0.9 considered abnormal) is useful for the detection of PAD. Tests that largely exclude PAD are the presence of ABI 0.9-1.3, toe brachial index ≥0.75 and the presence of triphasic pedal Doppler arterial waveforms. (strong; low) 4. In patients with a foot ulcer in diabetes and PAD, no specific symptoms or signs of PAD reliably predict healing of the ulcer. However, one of the following simple bedside tests should be used to inform the patient and healthcare professional about the healing potential of the ulcer. Any of the following findings increases the pre-test probability of healing by at least 25%: a skin perfusion pressure ≥40 mmHg, a toe pressure ≥30 mmHg or a transcutaneous oxygen pressure (TcPO 2 ) ≥25 mmHg. (strong; moderate) 5. Consider urgent vascular imaging and revascularisation in patients with a foot ulcer in diabetes where the toe pressure is <30 mmHg or the TcPO 2 <25 mmHg. (strong; low) 6. Consider vascular imaging and revascularisation in all patients with a foot ulcer in diabetes and PAD, irrespective of the results of bedside tests, when the ulcer does not improve within 6 weeks despite optimal management. (strong; low) 7. Diabetic microangiopathy should not be considered to be the cause of poor wound healing in patients with a foot ulcer. (strong; low) 8. In patients with a non-healing ulcer with either an ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularisation. (strong; moderate) 9. Colour Doppler ultrasound, computed tomography angiography, magnetic resonance angiography or intra-arterial digital subtraction angiography can each be used to obtain anatomical information when revascularisation is

show abstract

Commentary: Myths and Proofs of Angiosome Applications in CLI: Where Do We Stand?

Cited by 18 publications

References 45 publications

Ischemic Ulcer Healing: Does Appropriate Flow Reconstruction Stand for All That We Need?

Ischemic Ulcer Healing: Does Appropriate Flow Reconstruction Stand for All That We Need?

Oximetric angiosome imaging in diabetic feet

IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes

Contact Info

Product

Resources

About