The angiosome theory to guide revascularization for CLI Richard F. Neville, MD Associate Director, INOVA Heart and Vascular Institute Vice Chairman, Department of Surgery Director, Vascular Services

Scientific Advisory Board: Richard F. Neville, MD Disclosures   Scientific Advisory Board: WL Gore Graftworx   Cormatrix Tissue Analytics

Angiosome concept Angiosome – 3D anatomic unit fed by a source artery taYLO Angiosome – 3D anatomic unit fed by a source artery Defined 40 in the body Taylor, et al. Br J Plastic Surgery 1987:40:113

Angiosomes of the lower leg and foot 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 The foot and ankle comprises 5 distinct angiosomes: 3 from the distal branches of the posterior tibial artery, 1 by the dorsalis pedis artery, and 1 by the peroneal artery. Cadaveric dissection with colored latex injections Attinger CE, et al. Plastic and Reconstr Surg 2006:117;261S-293S 4

Angiosome: Anterior Tibial Artery Dorsalis pedis Anterior compartment Dorsum of foot

Angiosome: Peroneal Artery Lateral calcaneal Lateral ankle Lateral plantar heel Anterior perforator Medial ankle

Angiosome: Posterior Tibial Artery Medial plantar Lateral plantar Calcaneal Lateral ankle/forefoot

Angiosome: Indirect connections “Choke vessels” Importance of intact pedal arch

Does it make a difference in real world practice?

Angiosome based revascularization Implications for healing 60 consecutive ischemic lower extremity wounds Bypass for revascularization Preoperative arteriograms Arterial anatomy relative to each wound’s angiosome Bypass anatomy Bypass anatomy relative to each wound’s angiosome Standardized wound care per protocol Neville RF, et al. Ann Vasc Surg 2009; 23(3):367-373.

Angiosome based revascularization Direct vs Indirect Direct Revascularization (DR) Bypass to the artery perfusing the angiosome in which the wound was located Indirect Revascularization (IR) Bypass to an artery not directly perfusing the angiosome in which the wound was located IR DR

Angiosome based revascularization Patient Demographics IR Male Female 48% 52% 45% 55% Diabetes Mellitus 85% 89% Hypertension 32% CHF 10% 13% CAD 27% 31% Renal Failure Diabetes and ESRD similar between groups

Angiosome based revascularization Target artery 100% tibial bypasses No difference between groups

Angiosome based revascularization Soft tissue / Wound Care IR Primary closure / STSG 35% 24% Local amputation Ray/TMA/Chopart 60% 69% Free flap 5% 7% No difference in wound care between groups

Angiosome based revascularization Degree of healing Better complete healing with direct revascularization of the appropriate angiosome Direct revascularization Indirect revascularization 91% 62% P = 0.03 15

Angiosome based revascularization Time to healing Trend for faster healing with direct angiosome revascularization 16

Angiosomes and bypass Oregon Health Sciences University Single center, 106 limbs Complete healing (p=.001) DR 78% IR 46% Time to healing (p=.002) DR 99 days IR 195 days “DR is a significant predictor for wound healing and reduced healing time” Kret et al. J Vasc Surg 2014;59:1:121-8.

Angiosomes and bypass 58 bypasses DR 36, IR 22 Crural bypass for tissue loss Healing time shorter in the DR group 56 days vs 112 days Limb salvage higher in DR group 1 year: 91% vs. 66% 3 years: 65% vs. 24% 5 years: 58% vs. 18% “Achieving direct arterial flow based on the angiosome concept appears to be important for ulcer healing and limb salvage” Lejay A, et al. Ann Vasc Surgery 2014;28(4):983-9.

Angiosomes and endovascular therapy 203 ischemic ulcers Procedures Iliac PTA 17% SFA stenting 54% Tibial PTA 82% Healing DR 86% IR 69% Iida, et al. Endo Today 2010;September:96-100.

Angiosomes and endovascular therapy Healing of diabetic ischemic ulcers after endovascular revascularization DR 83% healed IR 59% healed “An angiosome model of perfusion, helps the treatment of diabetic foot ulcers” Alexandrescu, et al. J Endovasc Therapy 2008;15:580

Angiosomes for diabetic ulcers Helsinki University Hospital, Finland 250 patients, single center Ischemic diabetic ulcers Endovascular revascularization Infrapopliteal Healing at 12 months (p < .001) DR 72% IR 45% “The angiosome model is important for ulcer healing in diabetic patients” Soderstrom M, et al. J Vasc Surg 2013;57:427-35.

Angiosome revascularization for CLI Institute of Vascular Science, Bangalore, India Prospective study 64 patients with CLI Bypass 61%, Endovascular 39% Healing at 3 / 6 months (p=.021) DR 58% / 96% IR 13% / 83% “Angiosome should be considered whenever possible” Kabra et al. J Vasc Surg 2013;57(1):44-49.

Summary: Angiosomes are significant Direct revasc Indirect revasc Method Neville 91 62 Bypass Lejay 66 Alexandrescu 83 59 Endovascular Iida 86 69 Kret 78 46 Kabra 96 Bypass/Endo Soderstrom 72 45 Over 700 limbs studied

Conclusion Angiosome concept does have practical significance Revascularization of the appropriate wound angiosome does result in increased healing The angiosome concept should be considered in planning revascularization for healing and limb preservation

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