The comparative efficacy of angiosome‐directed and indirect revascularisation strategies to aid healing of chronic foot wounds in patients with co‐morbid diabetes mellitus and critical limb ischaemia: a literature review

Abstract

BackgroundIschaemic ulcerations have been reported to persist and/or deteriorate despite technically successful revascularisations; a higher incidence of which affects patients with diabetes and critical limb ischaemia. In the context of wound healing, it is unclear if applications of the angiosome concept in ‘direct revascularisation’ (DR) would be able to aid the healing of chronic foot ulcerations better than the current ‘best vessel’ or ‘indirect revascularisation’ (IR) strategy in patients with co-morbid diabetes and critical limb ischaemia.MethodsA literature search was conducted in eight electronic databases, namely AMED, CINAHL, The Cochrane Library, ProQuest Health & Medicine Complete, ProQuest Nursing & Allied Health Source, PubMed, ScienceDirect and TRIP database. Articles were initially screened against a pre-established inclusion and exclusion criteria to determine eligibility and subsequently appraised using the Newcastle-Ottawa Scale.ResultsFive retrospective studies of varying methodological quality were eligible for inclusion in this review. Critical analysis of an aggregated population (n = 280) from methodologically stronger studies indicates better wound healing outcomes in subjects who had undergone DR as compared to IR (p < 0.001; p = 0.04). DR also appears to result in a nearly twofold increase in probability of wound healing within 12 months (hazard ratio, 1.97; 95% CI, 1.34–2.90). This suggests that achieving direct arterial perfusion to the site of ulceration may be important for the healing of chronic diabetic foot ulcerations.ConclusionIncorporating an angiosome-directed approach in the lower limb revascularisation strategy could be a very useful adjunct to a solely indirect approach, which could increase the likelihood of wound healing. With the limited data currently available, findings appear promising and merit from further investigation. Additional research to form a solid evidence base for this revised strategy in patients with co-morbid diabetes and critical limb ischaemia is warranted.Electronic supplementary materialThe online version of this article (doi:10.1186/s13047-017-0206-5) contains supplementary material, which is available to authorized users.

Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update)

“…A recent retrospective study of endovascular limb salvage attempts in patients with DFU suggested that indirect angiosome revascularization was associated with poorer outcomes than direct revascularization . However, because of lack of clear definitions and factors like selection bias, the effectiveness of the angiosome concept in patients with diabetes is unknown . Particularly in patients with diabetes who usually have poor collaterals, restoration of flow to an artery directly supplying the affected area seems the best approach during an endovascular procedure .…”

“…57 However, because of lack of clear definitions and factors like selection bias, the effectiveness of the angiosome concept in patients with diabetes is unknown. 55,[58][59][60] Particularly in patients with diabetes who usually have poor collaterals, restoration of flow to an artery directly supplying the affected area seems the best approach during an endovascular procedure. 56 Successfully opening one or more occluded vessels is not the same as a clinically successful procedure and before the procedure is terminated blood flow to the ulcer area should therefore be assessed.…”

Infrapopliteal Angioplasty of One or More than One Artery for Critical Limb Ischaemia: A Randomised Clinical Trial

“…Regarding angiosome revascularisation, many studies of endovascular and open approaches have yielded results both in favour of 7e12 and against 3,13,14 the procedure. In a recent meta-analysis and systematic review, 15,16 it was suggested, despite reservations about low quality data and insufficient power for a definitive recommendation, that directed revascularisation (angiosome) could be associated with better wound healing and limb salvage. 15,16 In the recent 2017 ESC (European Society of Cardiology) Guideline in collaboration with the ESVS (European Society for Vascular Surgery), the direct strategy was recommended if the artery was accessible and open to the foot.…”

“…In a recent meta-analysis and systematic review, 15,16 it was suggested, despite reservations about low quality data and insufficient power for a definitive recommendation, that directed revascularisation (angiosome) could be associated with better wound healing and limb salvage. 15,16 In the recent 2017 ESC (European Society of Cardiology) Guideline in collaboration with the ESVS (European Society for Vascular Surgery), the direct strategy was recommended if the artery was accessible and open to the foot. 17 So, in many cases, considering the technical aspects of the diagnostic angiogram, the easiest artery to recanalise is treated instead of following the angiosome directed strategy.…”

Healing of Diabetic Neuroischemic Foot Wounds With vs Without Wound-Targeted Revascularization: Preliminary Observations From an 8-Year Prospective Dual-Center Registry

“…In a retrospective study of 70 diabetic patients, Jeon et al 37 observed a significant difference in healing (87% vs 47%, p<0.05) in the direct revascularization or angiosome-oriented subgroup vs IR interventions. Similarly, Khor et al 36 reviewed the literature on 280 diabetic subjects with critical limb ischemia treated by direct vs indirect revascularization strategy, finding not only better wound healing outcomes but also a nearly 2-fold increase in the probability of wound healing within 12 months (HR 1.97, 95% CI 1.34 to 2.90) for direct revascularization.…”