Can Angiosome-Based Revascularization Have An Impact In Limb Salvage?

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Author(s): 
Desmond Bell, DPM, CWS, FACCWS

   Subjecting patients to multiple digital and foot amputations, that in hindsight turn out to be futile, is taxing on patients, providers and even the healthcare system. Increasing the odds for success through the utilization of angiosomes and targeted revascularization is likely to prove an important next step in the evolution of lower extremity preservation.

   Dr. Bell is a board certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.

References
1. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40(2): 113-141.
2. Singh K. New treatment paradigm: the angiosome concept. Pod Today. 2012; 25(Suppl2):4-7.
3. Neville RF, Attinger CE, Bullan EJ, et al. Revascularization of a specific angiosome for limb salvage: does the target artery matter? Ann Vasc Surg. 2009; 23(3):367-373.
4. Iida O, Soga Y, Hirano K, et al. 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. J Vasc Surg. 2012; 55(2):363-370.

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Jeff Mennutisays: March 2, 2012 at 1:26 pm

I have had many consults regarding this same scenario. In my humble opinion, a majority of flow to the foot occurs via the posterior arteries. I would not have proceeded to TMA. Amputation should have been done at the level of occlusion. Flow only to the anterior portion of the foot would give mild viability of skin to dorsum of the foot, not enough to salvage a TMA. Perhaps a bypass should have been considered. Hopefully, nothing becomes of this.

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Desmond Bellsays: March 17, 2012 at 3:57 pm

Hi Jeff,

I appreciate your comments regarding this unfortunate patient.

First, I agree 100% with your assessment regarding the posterior tibial artery. Whether it be a heel ulcer or a plantar foot ulcer, if the PTA is occluded, the odds of a good clinical outcome decrease, whether it be healing of a wound or a surgical procedure. Not only is this point accurate purely from an intuitive understanding of the anatomy but an article by Guzman, Brinkley, et al discussed this. (See Guzman, Brinkley, et al. Tibial artery calcification as a marker of amputation risk in patients with PAD" J Am Coll Cardiol 2008;51(20):1967-1974.

In this case, the patient was NOT a bypass candidate. That had already been ruled out.
I presented this case more for the scenario that can happen when we are the ones left holding the "hot potato".

The patient underwent partially successful endovascular intervention below the knee with the DP being opened but attempt to open the PT was not successful. So to your point, he did have blood flow to the forefoot, albeit not from the posterior tibial artery.

Anyone who has performed limb preservation surgery during their career would probably agree that sometimes despite our best attempts, things may not work as we hope. In this case, options were presented to the patient and his family, including a below-knee amputation. The decision to attempt a TMA was based on further consultation with the endovascular specialist, who also recommended a TMA, in addition to the wishes of the patient.

Even though we knew going in that the PT remained occluded, our hope was that enough collateralization off the PT had occurred that would assist in supplying adequate blood flow to supplement the patent DP and peroneal arteries. The idea of a 50-50 chance of a successful TMA seemed worth the attempt versus the 0% chance the patient would have of walking on his own foot and leg that a BK amputation offered.

Again, the patient's surgery was technically beyond expectations as was his intraoperative perfusion. His foot remained warm for several days post-op until the plantar blanching became more evident.

I know there have been a number of cases I have performed where I was far less optimistic of a good outcome and yet the patients healed.

I felt that sharing this case was a great clinical illustration of the angiosome concept. An understanding of angiosomes, as well as some of the emerging interventional procedures that compliment surgical lower extremity bypass, can potentially 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 identifying critical limb ischemia cases that have an increased likelihood of failure where limb salvage surgery, such as amputation of a toe, partial forefoot amputation or even serial debridement, is being considered or attempted.

Thanks again for taking time to comment on the article.
Best regards,
Des

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