Pedal arch patency and not direct-angiosome revascularization predicts outcomes of endovascular interventions in diabetic patients with critical limb ischemia

Troisi, Nicola; Turini, Filippo; Chisci, Emiliano; Ercolini, Leonardo; Frosini, Patrizio; Lombardi, Renzo; Falciani, Francesca; Baggiore, Cristiana; Anichini, Roberto; Michelagnoli, Stefano

doi:10.23736/s0392-9590.17.03809-3

Cited by 41 publications

(28 citation statements)

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“…On the other hand, in some of the relevant studies where the healing was measured as a cumulative likelihood, no significant effect of any of the pertinent variables was found as well. 15,35 Apart from the above-mentioned possibility of late-look bias, this variability can be explained by the confounding effect of wound care protocol. According to Mii et al, 36 more aggressive debridement after revascularization for CLTI was able to decrease the mean healing time almost twice (from 82 to 48 days), overtaking the reported modest gain in wound closure speed after angiosomic revascularization versus revascularization via collaterals (e.g., 6.8 vs 7.9 months according to Alexandrescu et al 11 ).…”

Section: Discussionmentioning

confidence: 99%

“…Evidence to support this concept are very sparse. 7,13,14 Our study focused exclusively on patients with multilevel disease and excluded those with purely infrapopliteal disease, who have been amply investigated before in studies of the angiosome concept, [4][5][6][8][9][10][11][12][13][15][16][17] comprise a separate clinical entity of smaller vessel diameter, shorter affected segment, different patterns of collateral circulation and, therefore, were excluded.…”

Section: Discussionmentioning

confidence: 99%

“…All other variants of revascularization were classified as indirect. Pedal arch quality was defined according to Troisi et al 15 Complete pedal arch was defined when both the DPA and at least one of the plantar arteries were patent and joined to each other; incomplete pedal arch was defined when the DPA or one of the plantar arteries were patent but not joined to each other; and absent pedal arch was defined when neither the DPA nor at least one of the plantar arteries were patent.…”

Section: Endpoints and Definitionsmentioning

confidence: 99%

“…[4][5][6][7][8][9] However, evidence regarding the effect of DR has been conflicting, with some studies showing benefit for both limb salvage and wound healing, 4,5,10 yet others reporting only improved wound healing 5,[11][12][13][14] or even no difference at all. 15 The role of pedal arch and major collaterals was also reported. 4,8,[15][16][17] In recent years, the angiosome concept has been much debated, its possible benefit reconsidered and called into question.…”

Section: Introductionmentioning

confidence: 99%

“…15 The role of pedal arch and major collaterals was also reported. 4,8,[15][16][17] In recent years, the angiosome concept has been much debated, its possible benefit reconsidered and called into question. 1,18 Importantly, almost all studies of angiosomeoriented endovascular treatment included only infrapopliteal lesions.…”

Section: Introductionmentioning

confidence: 99%

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Propensity-matched analysis does not support angiosome-guided revascularization of multilevel peripheral artery disease (PAD)

Kurianov

Lipin²,

Antropov³

et al. 2021

Vasc Med

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Background: This retrospective comparative cohort study evaluated the clinical outcome of angiosome-guided endovascular arterial reconstructions in chronic limb-threatening ischemia (CLTI) due to multilevel peripheral artery disease (PAD). Methods: Patients treated in an endovascular fashion for CLTI with tissue loss due to multilevel PAD were analyzed. Limbs were classified as having undergone either angiosome-guided (direct) revascularization (DR) or nonangiosomic (indirect) revascularization (IR). DR was defined as uninterrupted in-line flow to the affected angiosome, revascularization through the pedal arch was also considered direct. Groups were adjusted with propensity score (PS) matching and compared for amputation-free survival (AFS), freedom from major adverse limb events (MALE), and healing rate at 12 months. Results: A total of 174 patients (81 men, mean age 70.0 ± 10.4 y) were included. PS matching produced two groups of 55 patients each: DR (24 men, mean age 71.7 ± 10.7 y) and IR (26 men, mean age 72.0 ± 9.4 y). The matched groups had no significant differences in baseline variables. At 12 months there were no significant differences in AFS (73.2% vs 71.6%; p = 0.841), freedom from MALE (71.7% vs 66.1%; p = 0.617), and healing rate (72.7% vs 72.0%; p = 1.000) between DR and IR, respectively. Conclusion: This study failed to support the use of angiosome concept in CLTI due to multilevel disease.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Endpoints and Definitionsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Propensity-matched analysis does not support angiosome-guided revascularization of multilevel peripheral artery disease (PAD)

Kurianov

Lipin²,

Antropov³

et al. 2021

Vasc Med

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

Forsythe

Apelqvist

Boyko

et al. 2020

Diabetes Metabolism Res

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In patients with diabetes, foot ulceration and peripheral artery disease (PAD), it is often difficult to determine whether, when and how to revascularise the affected lower extremity. The presence of PAD is a major risk factor for non‐healing and yet clinical outcomes of revascularisation are not necessarily related to technical success. The International Working Group of the Diabetic Foot updated systematic review on the effectiveness of revascularisation of the ulcerated foot in patients with diabetes and PAD is comprised of 64 studies describing >13 000 patients. Amongst 60 case series and 4 non‐randomised controlled studies, we summarised clinically relevant outcomes and found them to be broadly similar between patients treated with open vs endovascular therapy. Following endovascular revascularisation, the 1 year and 2 year limb salvage rates were 80% (IQR 78‐82%) and 78% (IQR 75‐83%), whereas open therapy was associated with rates of 85% (IQR 80‐90%) at 1 year and 87% (IQR 85‐88%) at 2 years, however these results were based on a varying combination of studies and cannot therefore be interpreted as cumulative. Overall, wound healing was achieved in a median of 60% of patients (IQR 50‐69%) at 1 year in those treated by endovascular or surgical therapy, and the major amputation rate of endovascular vs open therapy was 2% vs 5% at 30 days, 10% vs 9% at 1 year and 13% vs 9% at 2 years. For both strategies, overall mortality was found to be high, with 2% (1‐6%) perioperative (or 30 day) mortality, rising sharply to 13% (9‐23%) at 1 year, 29% (19‐48%) at 2 years and 47% (39‐71%) at 5 years. Both the angiosome concept (revascularisation directly to the area of tissue loss via its main feeding artery) or indirect revascularisation through collaterals, appear to be equally effective strategies for restoring perfusion. Overall, the available data do not allow us to recommend one method of revascularisation over the other and more studies are required to determine the best revascularisation approach in diabetic foot ulceration.

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The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer

Fitridge,

Chuter,

Mills

et al. 2023

Diabetes Metabolism Res

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Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post‐surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.

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Pedal arch patency and not direct-angiosome revascularization predicts outcomes of endovascular interventions in diabetic patients with critical limb ischemia

Cited by 41 publications

References 0 publications

Propensity-matched analysis does not support angiosome-guided revascularization of multilevel peripheral artery disease (PAD)

Propensity-matched analysis does not support angiosome-guided revascularization of multilevel peripheral artery disease (PAD)

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

The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer

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