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

Abstract

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."

Unusually low arcuate artery in a Kenyan cadaver

“…At the lateral aspect of the foot, it anastomoses with the lateral tarsal artery to form an arterial loop. It gives off the second through fourth dorsal metatarsal arteries which course between the toes, and each divides into two dorsal digital branches for the adjacent toe (1,2). Knowledge of the anatomical pattern of the arcuate artery is important for several reasons.…”

“…Lastly, it is important for understanding the concept and application of "topographical" or angiosome-guided bypasses to foot ischemic wounds (7) and endovascular "wound directed" revascularization (8), for assessing and judging the anatomical distribution of angiosomes, and collateral circulation in macro-and microcirculation (9). Several variations involving origin, course and branching have been reported (1,4,(10)(11)(12)(13). High origin has also been reported in several studies (6,12,14,15).…”

Current Issues and Interrogations in Angiosome Wound Targeted Revascularization for Chronic Limb Threatening Ischemia: A Review

“…These observations seem particularly to concern limb collateral-deprived subjects, such as diabetic and renal patients [7] [10]- [15]. Although there is currently a lack of solid evidence in angiosome-guided DR applications by classically following main angiosomal branches, recent publications suggest for adapting diagnostic and reperfusion strategies towards "wound-targeted revascularization" (WTR), if technically achievable [3] [14] [16] [17] [18] [19]. Always perceived as AC application, WTR proposes a wider apprehension of topographic arterial reperfusion, by including the available large collaterals, permeable foot arches (if present), and the arterial-arterial communicants between neighboring foot angiosomes [3] [10] [16] [17] [18] [19] (Figure 1).…”

“…A few contemporary studies add the WTR notion to DR, or to "DR-collateral enhanced" according to the AC [3] [10] [18] [19] as primary intention to treat CLTI. These studies reveal several observational advantages of this theory [10] [17] [18] [19] and obviously, some inherent uncertainties [20] [21] [22] [23].…”

“…In these patients, parallel efforts were exerted to improve the mean time to limb tissue recovery and decrease amputation rates by implementing the DR/WTR strategies [16] [17] [18] [19] [24]. This hypothesis also focuses on specific foot wound topographic reperfusion either via specific angiosomal branches (DR) or by using available local collateral reserves (WTR) [5] [10] [17] [18] [19] [26] in each given CLTI pattern, if technically attainable.…”