PNEC 2019
Predictors of Wound
Healing: Direct Angiosome
Perfusion vs. WIfIChristopher J. Abularrage, MD, DFSVS, FACSThe Bertram M. Bernheim Associate Professor of Surgery
Division of Vascular Surgery and Endovascular Therapy
The Johns Hopkins Hospital
DISCLOSUREChristopher J. Abularrage, MD
• No relevant financial relationship reported
Diabetic PADAngiosomes
• Angiosomes
• Concept defined by Ian Taylor in 1987
• Divides body into 3D anatomic units supplied by specific arteries
• Five units of the foot
Case #111/2015
• 61 year old
• PMH: DM, ESRD, CABG
• PSH: Left BKA (5/14), Right TMA (6/14),
• Right heel ulcer (7/14); Failed Apligraf
• Right SFA stent & Pop→AT stent
• Right lateral malleolar ulcer (7/15)
• ISR s/p repeat POBA (8/15)
• Failure to improve, recommended BKA
Case #1Bone scan + osteo calcaneus and fibula
PVR’s pulsatile
Right heel Right lateral malleolus
Case #112/2015 S/p debridement and fibular Integra
Right heel Right lateral malleolus
Case #11/2016 Failure of fibular Integra
Right heel Right lateral malleolus
Case #11/2016 Angio
Case #11/2016 Angio
Case #11/2016
• Vein mapping excellent
• Stress Test→ +reversible ischemia
• Cardiac Cath→ Unreconstructable
disease distal to patent grafts
• Trial of HBO
Case #12/2016
Right heel Right lateral malleolus
Case #12/2016
4mm POBAPre
Case #13/2016 S/p Heel STSG & fibular Integra
Right heel Right lateral malleolus
Case #16/2016 S/p Heel STSG & fibular Integra
Right heel Right lateral malleolus
Case #18/2016
Right lateral malleolus
Case #18/2016 (6mo s/p TP Trunk POBA)
4mm
PredilBuddy wire
4x38mm DES
Case #18/2016
Completion Angio
Case #114 mo after initial presentation
9/2016 1/2017
Diabetic PADAngiosomes
• 121 direct vs. 129 indirect limbs
• All endovascular interventions
Diabetic PADAngiosomes
P<.001
Soderstrom M et al. J Vasc Surg. 2013;57:427-35
Propensity Score
Analysis
1. Adjusted for pre-tx
variables
2. In-line revascHR 1.97, 95%CI 1.34-2.90;
P=.001
Conclusion
Endo adequate if inline
flow acheived
Definitions
• Direct Perfusion/Revascularization
• Open line from aorta to the artery supplying the wound angiosome (Lida)
• Heel and forefoot are PT (Alexandrescu)
• The angiosome artery revascularizedmatches that of the foot loss (Attinger)
• Little consensus when wounds span more than one angiosome
Open vs. Endo
What about the wound?
The WIfI Classification
The WIfI ClassificationValidation
The WIfI Classification
Definitions
• Compare predictive ability of WIfI classification vs
direct angiosome perfusion for wound healing
• Direct Angiosome Perfusion
– Any artery supplying the angiosome was patent or
revascularized
• Pedal arch patency (Rutherford)
– 0: Widely patent with retrograde flow
– 1: Widely patent without retrograde flow
– 2: Diseased or partially occluded pedal arch
– 3: Little or no pedal arch
Primary Outcome
• Wound Healing at one year
• Management
– Angiography with intent to perform
revascularization, preferentially direct
– Perfusion optimized if no direct options
– Debridement, local wound care, minor amputation
Study Cohort
99 Patients
225 Wounds
• Mean age 63 years
• 62.6% male
• Hypertension 87.9%
• Dyslipidemia 65.7%
• Tobacco Use 54.5%
• Hgb A1c 8.4%
• Insulin 56.6%
Wound Characteristics
May 25, 2019 72
Results
Results
P<.001
P=.89
Results
Results: Subanalysis
76
Conclusion
• More severe WIfI wounds were 23% less
likely to heal at 1 year.
• While direct angiosome perfusion was not
related to wound healing, it may be important
for higher WIfI stage wounds.
• WIfI classification has broad applicability.
• WIfI stage should be standard inclusion in all
future angiosome studies.
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