Primary infragenicular angioplasty for diabetic neuroischemic foot ulcers following the angiosome distribution: a new paradigm for the vascular interventionist?

Abstract

The angiosome principle was first described by Jan Taylor in 1987 in the plastic reconstructive surgery field, providing useful information on the vascular anatomy of the human body. Specifically concerning foot and ankle pathology, it may help the clinician to select better vascular access and specific strategies for revascularization. This knowledge may be particularly beneficial when treating diabetic neuroischemic foot wounds associated with particularly aggressive atherosclerotic disease and a poor collateral circulation. The implementation of angiosome-based strategies in diabetic infragenicular vascular reconstruction may afford encouraging wound healing and limb preservation rates using both bypass and endovascular techniques. The minimal invasiveness of these novel strategies enables us to perform more specific and more distal tibial and/or foot arterial reconstructions, in one or multiple targeted vessels. This paper reviews the available literature on this revascularization strategy and focuses on the potential benefit of angiosome-guided primary angioplasty for diabetic ischemic foot ulcers.

Clinical implications of the angiosome model in peripheral vascular disease

“…28 There is escalating interest in this area. 10,44 However, caution needs to be exercised that direct revascularization attempts into a specific angiosome should not supersede good surgical judgment.…”

Endovascular Treatment of Diabetic Foot in a Selected Population of Patients with Below-the-Knee Disease: Is the Angiosome Model Effective?

“…We then separated the treatment groups into twopatients undergoing DR and patients undergoing IR, according to the angiosome model [19]-so we could compare the different outcomes of the clinical laboratory studies, including TcPO 2 .…”

“…Many, however, are limited by the presence of a heterogeneous population with different stages of ischemia (claudication, rest pain, trophic lesions) and different treatment modalities, with PTA performed both in the above-the-knee (ATK) and BTK areas [15][16][17]. It is well known that peripheral arterial disease in diabetic patients with critical limb ischemia (CLI) primarily involves the BTK area (anterior and posterior tibial arteries, peroneal artery, dorsalis pedis, medial and lateral plantar arteries) [18], but the efficacy of PTA in this group of BTK-only patients has not been fully evaluated, particularly regarding the different effectiveness of direct revascularization (DR) versus indirect revascularization (IR) according to the angiosome model [19].…”

Threatening Inferior Limb Ischemia: When to Consider Fasciotomy and What Principles to Apply?

“…In these selected presentations, the CS may follow the topography of chronic inflammation and ischemic foot wounds [20,21]. Since collateral compensation is abolished among different anatomical foot sectors, specific angiosome revascularization may trigger confined regional reperfusion syndromes (according the preexisting fibrous tracts) [10,22,23]. Among the whole of the cited foot compartments [2,7,13], the interosseous sectors seem to be the most affected zones by CS, after releasing critical ischemic foot injuries [10,18,20,24].…”

“…Taking in account the dominance of posterior tibial (PT) arterial flow in the hind foot angiosomes [10,[20][21][22][23][24], the vascular interventionist should be aware of possible revascularization CS arising in this region. Specifically for these three posterior compartments, sole PT artery reopening in circumstances of severe local sepsis and collateral decay (e.g., for diabetic foot wounds) [21,23] may enhance confined flexors tracts swelling [13,24] requiring post-or perioperative (simultaneously to tissue debridement) decompression [10,13,18,24].…”