Angiosome theory: a myth or a

reality

George Kouvelos MD, PhD, FEBVS

Department of Vascular Surgery

University of Thessaly, Larissa, Greece

CLI in diabetics

• In diabetics, atherosclerotic lesions are mostly located in the crural arteries

• contemporary revascularization series report a 10%–18% rate of unhealed ischemic wounds and frustrating major amputations despite good bypass patency or successful endovascular treatment

• there is a need to identify methods to optimize the arterial supply to the ulcer area

Angiosome concept

Six distinct angiosomes:

• Anterior tibial artery (1)• Dorsalis pedis

• Peroneal artery (2)• Lateral calcaneal• Anterior perforator

• Posterior tibial artery (3)• Calcaneal• Medical plantar• Lateral plantar

Angiosomes

✓ Introduced by Taylor and Palmer in 1987

Posterior Circulation – Posterior Tibial / Plantar Arch

Anterior Circulation – Dorsalis Pedis

Connection between Anterior & Posterior Circulation Plantar – Pedal Arch

Hypothesis – Foot Angiosomes

• Foot revascularization (bypass, endovascular) based on the angiosome concept of tissue perfusion will result in improve ulcer healing and limb salvage

• Two patient treatment groups

– Direct - tibial artery angiosome revascularized

– Indirect – ulcerated angiosome fed by collaterals from other angiosomes

Do we have comparative studies?

52 wounds in 48 patients• Open revascularisation✓ 51% Direct Revascularisation✓ 49% Indirect RevascularisationWound healing:DR: 91%IR: 62%• AmputationDR: 9%IR: 38%

Neville et al, Ann Vasc Surg 2009

369 limbs in 329 patientsEndovascular treatment✓ 200 DR; 169 IR✓ Mean FU: 18 mths• LS rate: 82 vs 68% @ 4 y (p:0.02)AFS: 49 vs 29% @ 4 y (p:0.002)Freedom from MALE51 vs 28% @ 4 y (p:0.008)

Lida et al, J Vasc Surg 2012

wound healing rate is better

Elbadawy et al, Eur J Vasc Endovasc Surg 2018

Amputation free survival Limb salvage

Elbadawy et al, Eur J Vasc Endovasc Surg 2018

Bosanquet et al, Eur J Vasc Endovasc Surg 2014

So…

✓ Should we take the angiosome concept into account in our revascularisation strategy?

✓How often do we really have the choice?

✓ Should we still perform indirect revascularisations?

Key point Look at the outflow!

Foot arteries are the borderbetween two different worlds,two different diseases interms of biology and clinicalevolution: LAD & SAD

LAD = Large Artery DiseaseSAD = Small Artery Disease

The value of an angiosome-orientedrevascularization is inversely related tothe function of collateral vessels

LAD without SADCollateral vessels are generally spared-good foot distribution system

We can do BP-PTA looking

for the healthy foot

distribution system.

The value of an angiosome-orientedrevascularization is inversely related tothe function of collateral vessels

SAD with/without LADCollateral vessels are generally involved failure of the foot distribution system

The value of an angiosome-orientedrevascularization is inversely related tothe function of collateral vessels

SAD with/without LADCollateral vessels are generally involved failure of the foot distribution system

In SAD patients angiosome orientedrevascularization,when possible, is the best way to get healing

Other revascularization factors are also important…

✓Patency

✓Choice of conduit

✓Inflow

✓Type of lesion

In clinical practice…

With open surgery for limb salvage

✓ Angiosome targeted bypass if good outflow artery. If

not, we should choose the best outflow artery,

because the perfusion increases also in the adjacent

angiosomes

In clinical practice…

For endovascular treatments for limb salvage

✓ To achieve wound healing, the best choice is to

perform angiosome targeted endovascular

revascularization

✓ nontargeted endovascular revascularization if clear

collaterals to the wound angiosome from the treated

artery does not exist

Conclusion

• Revascularization of the appropriate angiosomeseems to result in increased healing and limb salvage rates

• Quality of evidence is low

• There are certainly situations that angiosomebased revascularization really matters and makes a difference when it can be utilized

More data are needed…

✓wider-scale clinical experience in randomized and

prospective cohort studies are mandatory

Thank you for

your attention!