What Is the Angiosome Concept?cacvsarchives.org/archivesite/2014/pdf...What Is the Angiosome...
Transcript of What Is the Angiosome Concept?cacvsarchives.org/archivesite/2014/pdf...What Is the Angiosome...
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What Is the Angiosome Concept? Is It More Useful Than Pedal Arch Patency?
Peter A. Schneider, MD
Kaiser Foundation Hospital
Honolulu, Hawaii
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Disclosure
Speaker name: Peter A. Schneider
.................................................................................
I have the following potential conflicts of interest to report:
Chief Medical Officer for Intact Vascular
Modest royalty from Cook
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Rutherford 4
Rest pain
Rutherford 5
Minor tissue loss
Rutherford 6
Major tissue loss
Not all CLI is created equally
Kaplan-Meier 12 Month Freedom from Major Amputation
by Baseline Rutherford Criteria
0.959 0.943 0.926 0.9090.882
0.988
0.7010.765
0.00
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0 30 60 90 120 150 180 210 240 270 300 330 360 390
Days
Perc
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t E
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t-F
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Rutherford 4 Rutherford 5 Rutherford 6
XCELL Trial
Rocha-Singh et al. CC&I 2012
We know that these conditions are not interchangeable!
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Angiosome Concept
• CLI is a perfusion deficit
• Are tibial arteries interchangable?
• Targeted tibial revascularization
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Old Teachings
• “Must establish in-line flow to the foot”
– Typically with bypass, we are looking for the
best quality target blood vessel to work with.
Study CLI Patients Results
Goodney at al Ann Vasc Surg 2010;24:59
2306 bypass 8% amputation at one year, 17% of these had a patent bypass
Simons et al. J Vasc Surg 2010;51:1419
1012 bypass 10% of those with a patent graft had no clinical improvement
Limb Amputation or Clinical Failure Despite a Patent Bypass
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Iida et al. J Vasc Surg 2012;55:363
Targeted tibial revascularization
– Opportunity to match the treatment to the
clinical syndrome. Why not achieve best
possible perfusion to the tissue in need?
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We are taught that these
are fully anastomotic arteries.
When the pedal arch is patent,
the need for direct angiosomal
revasc is diminshed or negated.
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CLI patients, especially diabetics
have compartments of pedal flow.
4+ pulse
Ulcer
No pulse
These are supposed
to be anastomotic arteries
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Angiosome Concept
Compartmentalized flow in the foot.
We need targeted revascularization.
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Attinger. Plast Reconstr Surg 2006;117:261
Angiosomal Anatomy Medial plantar artery
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Kabra et al. J Vasc Surg 2013;57:44
Faster Wound Healing with Direct Revascularization
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Kabra et al. J Vasc Surg 2013;57:44
Improved Limb Salvage with Direct Revascularization
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Method of Revasc
Study Appropriate Angiosome
Boundary Angiosome
Bypass Neville Ann Vasc Surg, 2009
91% healed 62% healed
Kret J Vasc Surg 2014
85% healed/1y 62% healed/1y
PTA Alexandrescu J Endovasc Ther 2008
83% healed 59% healed
Alexandrescu J Endovasc Ther 2011
90% limb
salvage/2years
78% limb
salvage/2years
Iida CCI 2010
86% limb
salvage/2years
69% limb
salvage/2years
PTA/Bypass Kabra J Vasc Surg 2013
96% healed/6m 83% healed/6m
Results of Angiosomal Perfusion
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Iida et al. J Vasc Surg 2012;55:363
Isolated
Below-the-knee Lesions
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Iida et al. Eur J Vasc Endovasc Surg 2013;46:575
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Kret et al. J Vasc Surg 2014;59:121
Wound healing was faster.
Limb salvage was the same.
Angiosome helpful in about
half the patients.
Only about 1/3 of wounds fit
neatly into a specific angiosome.
Direct Revascularization in Bypass Patients
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Rashid et al. J Vasc Surg 2013;57:1219.
In a study of bypass,
a patent pedal arch
was more important
than the angiosome.
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When is Angiosome Strategy
Less Important?
• Fully intact pedal arch, more likely in non-diabetics
• Rutherford 4-no tissue loss, revasc any vessel
• Rutherford 6-crosses angiosomes, revasc all arteries
• Lesion above the ankle
• Superficial ulceration (<10mm in diameter), esp. if toe
pressure >50mmHg after PTA
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Angiosome Concept
How Can It Guide Therapy?
• Patent target in correct angiosome that
cannot be revascularized by endovascular
means should get a bypass, especially if
there is major foot damage.
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Angiosome Concept
How Can it Guide Therapy?
• Rutherford 5: Which tibial to revascularize?
• Rutherford 6: How many tibials to
revascularize?
• When to do a bypass?
– How long to follow post-angioplasty before
considering bypass?
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What Is the Angiosome Concept?
Conclusion
• An opportunity for targeted therapy.
• Healing is more likely and faster after
direct revasc of the correct angiosome.
• Angiosome concept helps explain some
of the variability in results of revasc for
CLI, especially in diabetics with
compartmentalized pedal circulation.