Can Angiosome-Based Revascularization Have An Impact In Limb Salvage?
I made an immediate referral to an interventional cardiologist, who performed an arteriogram as an in-patient procedure within 24 hours of my initial evaluation.
Occlusions at the dorsalis pedis and posterior tibial arteries were present. The interventional cardiologist attempted to open both vessels but reperfusion was only successful at the dorsalis pedis. The posterior tibial artery was calcified beyond repair.
Further ischemic changes occurred at the three medial toes. At that point, the foot was considerably warmer and capillary refill occurred at the lateral fourth and fifth toes. We obtained Doppler pulses at the dorsalis pedis but not at the posterior tibial artery. We recommended a transmetatarsal amputation as a limb preservation option and the patient consented.
Intraoperatively, the case could not have gone any better. The patient had excellent perfusion and anatomically, the foot had no deformities from prior diabetes-related infections, degenerative or iatrogenic causes. The total time from start to finish of the procedure was approximately 30 minutes. The patient did well in the immediate 48 hours postoperatively and seemed to be heading toward an uneventful recovery until approximately the fifth day after the procedure.
At that point, a distinct color change occurred along the plantar distal medial aspect of the foot. This deteriorated over the next week as sloughing of the skin, further demarcation and eschar formation occurred and intensified.
The knowledge that the posterior tibial artery could not be opened, coupled with the extent of further ischemic changes along the posterior tibial angiosome, helped lead to the decision to recommend the patient for a below-knee amputation. This occurred approximately three weeks after the initial transmetatarsal amputation. Postoperatively, after the below-knee amputation, the patient’s condition deteriorated and he subsequently died less than three months after presenting with discoloration of his toes.
This case illustrates that even though a targeted angiosome-directed approach to revascularization appears to be validated by preliminary evidence, sometimes even the best-laid plans are unsuccessful. The degree and extent of calcification of lower extremity arteries is still the final factor as to whether one can successfully open an occluded artery and preserve an ischemic lower extremity.
An understanding of angiosomes, as well as some of the emerging interventional procedures that compliment surgical lower extremity bypass, can improve critical limb ischemia outcomes. Not only can the clinical application of the concept result in better outcomes but conversely, it may provide greater prognostic value in determining which salvage cases are more likely to fail.