Deep calf veins arterialization for inferior limb preservation in diabetic patients with extended ischaemic wounds, unfit for direct arterial reconstruction: preliminary results according to an angiosome model of perfusion

Alexandrescu, Vlad; Ngongang, Christian; Vincent, Gaetane; Ledent, Gilles; Hubermont, G.

doi:10.1016/j.carrev.2009.12.002

Cited by 54 publications

(49 citation statements)

References 14 publications

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“…Similar to other authors, we found poor healing of incisional wounds on the foot to be of importance for poor limb salvage. This experience seems to favor using a more proximally located distal anastomosis combined with endovascular valve destruction and closure of arteriovenous fistula in a manner more similar to the technique originally described by Alexandriescu (11). For this initial group of patients, evaluation was only based on clinical assessment.…”

Section: Discussionmentioning

confidence: 94%

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Early results from an angiosome-directed open surgical technique for venous arterialization in patients with critical lower limb ischemia

Houlind

Christensen

Hallenberg

et al. 2013

Diabetic Foot & Ankle

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BackgroundPatients with critical lower limb ischemia without patent pedal arteries cannot be treated by the conventional arterial reconstruction. Venous arterialization has been suggested to improve limb salvage in this subgroup of patients but has not gained wide acceptance. We report our early experience after implementing deep and superficial venous arterialization of the lower limb.Materials and methodsTen patients with critical ischemia and without crural or pedal arteries available for conventional bypass surgery or angioplasty were treated with distal venous arterialization. Inflow was from the most distal unobstructed segment. Run-off was the dorsal pedal venous arch (n=5), the dorsal pedal venous arch and a concomitant vein of the posterior tibial artery (n=3), or the dorsal pedal venous arch and a concomitant vein of the common plantar artery (n=2) depending on the location of the ischemic lesion. Venous valves were destroyed using antegrade valvulotomes, guide wires, knob needles, or retrograde valvulotomes via an extra incision.ResultsSeven of the operated limbs were amputated after 23 (1–256) days (median [range]). The main reasons for amputation were lack of healing of either the original wound, of incisional wounds on the foot, or persisting pain at rest. In three cases, the bypass was open at the time of amputation. Two patients experienced complete wound healing after 231 and 342 days, respectively. By the end of follow-up, the last patient was ambulating with slow wound healing but without pain 309 days after surgery.ConclusionVenous arterialization may be used as a treatment of otherwise unsalveable limbs. The success rate is, however, limited. Technical optimization of the technique is warranted.

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Section: Discussionmentioning

confidence: 94%

“…Recently, Alexandriescu et al added the concept of angiosome-directed revascularization, originally introduced by Taylor and Attinger (9–11) to a partly endovascular technique for venous arterialization. This technique did not, however, comply with the principle of placing the anastomosis as distally as possible.…”

mentioning

confidence: 99%

Early results from an angiosome-directed open surgical technique for venous arterialization in patients with critical lower limb ischemia

Houlind

Christensen

Hallenberg

et al. 2013

Diabetic Foot & Ankle

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“…Some studies looked at primary revascularization and excluded those patients with previous interventions, 17-20 while others described the angiosome approach when used as a salvage procedure in patients with previously failed attempts at revascularization. 21 Some studies looked retrospectively at the results of patients in whom successful revascularization had been undertaken, recording whether this had been achieved by targeting the source artery supplying the affected angiosome (equivalent to DR) or not. 19,20,[22][23][24][25] Other studies compared the use of DR or IR in their patient series, recording outcomes of each technique and thereby examining whether DR is technically possible and effective for treatment of lower limb ischemic ulceration and, if so, how it compares with the results of IR.…”

Section: Role Of Direct Revascularization Of An Affected Angiosomementioning

confidence: 99%

“…19,20,[22][23][24][25] Other studies compared the use of DR or IR in their patient series, recording outcomes of each technique and thereby examining whether DR is technically possible and effective for treatment of lower limb ischemic ulceration and, if so, how it compares with the results of IR. 18,21,26,27 Patient comorbidities were included in all studies (Table II). Patients with diabetes were included in all studies and were predominant in nine papers (>80% patients with diabetes).…”

Section: Role Of Direct Revascularization Of An Affected Angiosomementioning

confidence: 99%

Clinical implications of the angiosome model in peripheral vascular disease

Sumpio

Forsythe

Ziegler

et al. 2013

Journal of Vascular Surgery

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Vascular surgery has seen a revolutionary transformation in its approach to peripheral vascular disease over the last 2 decades, fueled by technological innovation and a willingness by the field to adopt these changes. However, the underlying pathology behind critical limb ischemia and the significant rate of unhealed wounds and secondary amputations despite apparently successful revascularization needs to be addressed. In seeking to improve outcomes, it may be beneficial to examine our approach to vascular disease at the fundamental level of anatomy, the angiosome, to better dictate reperfusion strategies beyond a simple determination of open vs endovascular procedure. We performed a systematic review of the current literature concerning the significance of the angiosome concept in the realm of vascular surgery. The dearth of convincing evidence in the form of prospective trials and large patient populations, and the lack of a consistent, comparable vocabulary to contrast study findings, prevent recommendation of the conceptual model at a wider level for guidance of revascularization attempts. Further well-structured, prospective studies are required as well as emerging imaging strategies, such as indocyanine green dye-based fluorescent angiography or hyperspectral imaging, to allow wider adoption of the angiosome model in vascular operations.

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“…Diverting flow in a retrograde direction through the venous circulation is a feasible alternative that is supported by evidence from countless published studies. [1][2][3][4][5][6][7][8][9][10][11][12][13] The concept is based on the theory that in the absence of primary arterial blood pressure in arterioles, blood supplied by arterialization of the distal venous system is capable of supplying the peripheral tissues and providing adequate oxygenation. [3][4][5]13 Many different variables have been used to evaluate tissue hypoxia in animal models, such as assessment of arterial flow using Doppler ultrasound (US), 14,15 temperature measurements, 16 blood gas analysis, 17 lactate 18 and creatine phosphokinase (CP) assays, 19 and measurements of arterial blood pressure at extremities.…”

Section: Introductionmentioning

confidence: 99%

Isquemia e reperfusão por circulação retrógrada: estudo comparativo experimental

et al. 2017

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Background: There are few options for treating critical ischemia in limbs with no distal patency. Diverting flow through the venous circulation is an option supported by evidence from numerous published studies. Objectives: To compare the behavior of clinical and laboratory variables between the hind limbs of pigs subjected to ischemia and to ischemia with reperfusion by retrograde circulation and between these intervention groups and a control group. Methods: Ten pigs were divided into 2 groups. In group 1 (n=5), controls, patterns of physiological variables such as flow according to Doppler ultrasound, temperature, blood gas analysis results, lactate, creatine kinase, and blood pressure were evaluated. In group 2 (n=5), after an initial ischemia period with mean duration of 27 minutes and 30 seconds, provoked by interrupting flow through the femoral arteries, the animals were subjected to venous arterialization of the left hind limb while the right hind limb was maintained in ischemia. Variables were analyzed separately for each hind leg at 0, 2, 3, 4, and 6 hours after reperfusion and compared against each other and the control group. Results: Analysis of variables from both procedures showed decreases in BE and PO 2 and significant increases in lactate and creatine kinase, in relation to the control group. In arterialized ischemic limbs, we observed flow on Doppler ultrasound, and arterial pressures and temperatures were higher than in the ischemic limbs. Conclusions: Comparative analysis of the extremities in ischemia and arterialized ischemia showed, in relation to the control group, metabolic acidosis with significant increases in lactate and creatine kinase, suggesting cellular damage, and there were signs of retrograde reperfusion in arterialized extremities.

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Deep calf veins arterialization for inferior limb preservation in diabetic patients with extended ischaemic wounds, unfit for direct arterial reconstruction: preliminary results according to an angiosome model of perfusion

Cited by 54 publications

References 14 publications

Early results from an angiosome-directed open surgical technique for venous arterialization in patients with critical lower limb ischemia

Early results from an angiosome-directed open surgical technique for venous arterialization in patients with critical lower limb ischemia

Clinical implications of the angiosome model in peripheral vascular disease

Isquemia e reperfusão por circulação retrógrada: estudo comparativo experimental

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