Diapositive 1

How much does the angiosome concept really matter? Marco Manzi, MD Interventional Radiology UnitFoot & Ankle ClinicRegional Center of Reference for the Treatment of Diabetic FootPoliclinico Abano, Abano Terme (PD)ITALY

Abbott Vascular: Consultant

BARD/Clearstream: Consultant

COOK: Consultant

Covidien/EV3: Proctor

Boston Scientific: Proctor

Medtronic-Invatec: ConsultantMarco MANZI MD DISCLOSURES

Three-dimensional blocks of tissue fed by source arteries

Ian Taylor1

1 The vascular territories (angiosomes) of the body: Experimental studies and clinical applications, Taylor, GI and Palmer JH. Br. J. Plast. Surg. 1990;43.

UNDERSTANDING ANGIOSOMES

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Angiosome:Anterior TibialAngiosome:Peroneal Calcanear Branch

Angiosome:Posterior TibialUNDERSTANDING ANGIOSOMES

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Normal The acute occlusion of one of the TIBIAL or FOOT arteries could be immediately be compensated by the ANASTOMOTIC SystemUNDERSTANDING ANGIOSOMES

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DM UNDERSTANDING ANGIOSOMES

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SHIFT TO A TERMINAL LIKE CIRCULATION

Thats why The Model Can Work!UNDERSTANDING ANGIOSOMES

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Wound Healing Based on Revascularization of the Appropriate AngiosomeNeville RF, Attinger CE, Ann Vasc Surg 2009; 23(3):367-373Direct 91% vs 62% Indirect p=0,03ANGIOSOMES RELEVANCE FOR TREATMENT

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Texas University Classification and prevalence of amputations within each wound categoryArmstrong D. et al: Validation of a diabetic wound classification system. Diabetes Care Vol.21 n.5 855 (1998)TUC 1CTUC 2 CTUC 3CTUC 3DANGIOSOMES & Clinical Indications

Unuseful Forefoot Revascularization

Preserved Loop Lost Loop ANGIOSOMES &Surgical Destiny

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OLD concept linked to Limb SalvageSingle VesselDirect Revascularization (bypass or PTA) better than IndirectAngiosomes & WRAComplete1 vessel better than 02-3 vessels better than 1Tibials better than PeronealKinds of Endorevascularization &ANGIOSOMESR. Ferraresi, L.M.Palena, G.Mauri, M.ManziBelow the Ankle Peripheral Artery Disease inP.Lanzer, E.J.Topol - Panvascular Medicine- 2014 Ed.

ANGIOSOME GUIDED?

Baseline and Intervention

Angio and Clinical Results

ANGIOSOME GUIDED ?

Incomplete Revascularization Sample

Clinical Results

Indicated in patients with deep infections, that involve more than one angiosome.Patients scheduled for forefoot amputations (trasmetatarsal, Lisfranc or Chopart) COMPLETE is BETTER than ANGIOSOME GUIDED

Wound Related Revasc Revascularization of the artery directly feeding the wound region.Indicated in ulcers involving only one angiosome.Patients scheduled for forefoot amputation can not be treated following the angiosome concept.

ANGIOSOME GUIDED

Revascularization Pattern SamplesWRA : Arterial Lesion clearly Related to a well demarcated foot wound

Indirect ? Was demonstrated that the restoration of the blood flow to the ulcer through the collaterals provide good results in terms of healing and limb salvage. (Varela et al. Vasc Endovasc Surg 2010; 44:654-660)

Revascularization Pattern Samples

52 year-old man: diabetes; CLI (TcPO2 = 1 mmHg); TUC - 3C; forefoot gangreneANGIOSOME GUIDED ?

Baseline Angiography 1.11.2011

AVFAcute Results

Clinical Results

CONCLUSIONS 1Angiosome guided / WR revascularization does matter in anatomically well demarcated lesions;Should be always related to the scheduled surgical option;

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CONCLUSIONS 2Complete revascularization is reccomended for huge wounds and deep infections or scheduled aggressive surgical treatment;More Studies are needed on the potential relationship between Angiosome guided/WR revascularization and time of healing

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THANK YOU FOR YOUR ATTENTION

Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions. Osamu Iida, Yoshimitsu Soga, Keisuke Hirano, Daizo Kawasaki, Kenji Suzuki, Yusuke Miyashita, Hiroto Terashi, Masaaki Uematsu Kansai Rosai Hospital Cardiovascular Center, Hyogo, Japan. iida.osa@gmail.com