Can Angiosome-Based Revascularization Have An Impact In Limb Salvage?
This author details the case of a 71-year-old patient who had reperfusion procedures for occlusions at the dorsalis pedis and posterior tibial arteries, and subsequently had transmetatarsal and below-knee amputations.
The advent of endovascular procedures, coupled with surgical bypass of the lower extremities and advances in wound healing technologies, has helped to enhance the importance of the team approach to limb preservation.
Identifying occluded arteries in the lower extremity and subsequently being able to open them to restore blood flow where gangrene was impending has preserved an ever-increasing number of legs that previously may have been doomed to amputation. Endovascular procedures have concomitantly extended the duration of life and improved the quality of life for many.
Taylor and Palmer introduced the concept of angiosomes.1 Conceptually analogous to neurological dermatomes, angiosomes provide a vascular mapping of the body, showing anatomical regions between the skin and bones that are supplied by specific arteries and veins.
Angiosome-based revascularization is the concept in which the target artery for reperfusion is the one associated with the ischemic angiosome. This direct revascularization approach is associated with higher limb-salvage rates than indirect revascularization, in which a non-angiosome vessel is the target.2
In independent retrospective analyses, Neville, Iida and their respective colleagues found that utilizing targeted direct angiosome revascularization resulted in significantly fewer amputations.2-4 These authors noted this also led to a higher amputation-free survival rate in comparison to non-angiosome guided indirect revascularization.2-4
Despite the best efforts of the treating clinicians, the following case did not have a good outcome. It does however provide a clinical application of the value of angiosomes and the importance of targeting arterial occlusion when considering revascularization.
When Attempted Reperfusion Fails In A 71-Year-Old Patient
A 71-year-old male presented with an approximately 25-year history of diabetes. After several years of intermittent treatment for right foot ulcers and osteomyelitis of his fifth metatarsal, the patient had been living uneventfully without any further foot ulcers or issues for nearly two years.
The patient called for an appointment with a new concern of “new wounds on his foot.” Upon expedited evaluation in my office, I discovered that the patient had ischemic changes to his left foot, specifically the medial three toes and forefoot that were consistent with critical limb ischemia.