Endovascular Treatment of Diabetic Foot in a Selected Population of Patients with Below-the-Knee Disease: Is the Angiosome Model Effective?

Fossaceca, Rita; Guzzardi, Giuseppe; Cerini, Paolo; Cusaro, C; Stecco, Alessandro; Parziale, Giuseppe; Perchinunno, Marco; Bonis, Marco De; Carriero, Alessandro

doi:10.1007/s00270-012-0544-4

Cited by 65 publications

(86 citation statements)

References 41 publications

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“…of patientsNo. of limbsAgeMale/FemaleEthnicityHTNDLPHistory of smokingESRD/on dialysisCADCVDFossaceca et al, 2013 [36] DR201-75.5 ± 9.5136 M/65 F-124 (62%)--15 (7%)65 (32%)- IR p -valuesNA----------Söderström et al, 2013 [37] DR22612168.4 ± 11.989 M/32 F-89 (74%)78 (65%)24 (18%)26 (22%)69 (57%)29 (24%) IR12973.8 ± 11.171 M/58 F-102 (79%)84 (65%)20 (24%)13 (10%)90 (70%)24 (19%) p -valuesNANA0.0010.002-NSNSNS0.0120.044NS DR: propensity score matched pairs-8471.7 ± 11.059 M/25 F-63 (75%)50 (60%)18 (25%)14 (17%)53 (63%)20 (24%) IR: propensity score matched pairs8470.3 ± 10.958 M/26 F-63 (75%)60 (71%)15 (20%)12 (14%)55 (66%)17 (20%) p -values: propensity score matched pairsNANANSNS-NSNSNSNSNSNSAcín et al, 2014 [38] DR46-72 (63–78)30 M/16 F-31 (67%)13 (28%)36 (78%)Excluded17 (37%)9 (20%) IR ‘through collaterals’22-…”

Section: Resultsmentioning

confidence: 99%

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The comparative efficacy of angiosome‐directed and indirect revascularisation strategies to aid healing of chronic foot wounds in patients with co‐morbid diabetes mellitus and critical limb ischaemia: a literature review

Khor

Price

2017

Journal of Foot and Ankle Research

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BackgroundIschaemic ulcerations have been reported to persist and/or deteriorate despite technically successful revascularisations; a higher incidence of which affects patients with diabetes and critical limb ischaemia. In the context of wound healing, it is unclear if applications of the angiosome concept in ‘direct revascularisation’ (DR) would be able to aid the healing of chronic foot ulcerations better than the current ‘best vessel’ or ‘indirect revascularisation’ (IR) strategy in patients with co-morbid diabetes and critical limb ischaemia.MethodsA literature search was conducted in eight electronic databases, namely AMED, CINAHL, The Cochrane Library, ProQuest Health & Medicine Complete, ProQuest Nursing & Allied Health Source, PubMed, ScienceDirect and TRIP database. Articles were initially screened against a pre-established inclusion and exclusion criteria to determine eligibility and subsequently appraised using the Newcastle-Ottawa Scale.ResultsFive retrospective studies of varying methodological quality were eligible for inclusion in this review. Critical analysis of an aggregated population (n = 280) from methodologically stronger studies indicates better wound healing outcomes in subjects who had undergone DR as compared to IR (p < 0.001; p = 0.04). DR also appears to result in a nearly twofold increase in probability of wound healing within 12 months (hazard ratio, 1.97; 95% CI, 1.34–2.90). This suggests that achieving direct arterial perfusion to the site of ulceration may be important for the healing of chronic diabetic foot ulcerations.ConclusionIncorporating an angiosome-directed approach in the lower limb revascularisation strategy could be a very useful adjunct to a solely indirect approach, which could increase the likelihood of wound healing. With the limited data currently available, findings appear promising and merit from further investigation. Additional research to form a solid evidence base for this revised strategy in patients with co-morbid diabetes and critical limb ischaemia is warranted.Electronic supplementary materialThe online version of this article (doi:10.1186/s13047-017-0206-5) contains supplementary material, which is available to authorized users.

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Section: Resultsmentioning

confidence: 99%

“…The numerous methodological flaws in three studies [36, 38, 40] leave their results vulnerable to type I and type II errors, making it injudicious to attribute weight to their findings.…”

Section: Discussionmentioning

confidence: 99%

The comparative efficacy of angiosome‐directed and indirect revascularisation strategies to aid healing of chronic foot wounds in patients with co‐morbid diabetes mellitus and critical limb ischaemia: a literature review

Khor

Price

2017

Journal of Foot and Ankle Research

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“…Mean time to healing was not significantly different in DR compared with IR when analyzed by three studies. One study found a significant increase in amputation-free survival in DR when compared with IR (evaluated by three studies 24,26,27 ). One study that demonstrated a significant difference in wound healing at 12 months with DR was undertaken by Varela et al, 20 however, this group also looked at the effect of collaterals on revascularization.…”

Section: Role Of Direct Revascularization Of An Affected Angiosomementioning

confidence: 97%

“…19,20,[22][23][24][25] Other studies compared the use of DR or IR in their patient series, recording outcomes of each technique and thereby examining whether DR is technically possible and effective for treatment of lower limb ischemic ulceration and, if so, how it compares with the results of IR. 18,21,26,27 Patient comorbidities were included in all studies (Table II). Patients with diabetes were included in all studies and were predominant in nine papers (>80% patients with diabetes).…”

Section: Role Of Direct Revascularization Of An Affected Angiosomementioning

confidence: 99%

Clinical implications of the angiosome model in peripheral vascular disease

Sumpio

Forsythe

Ziegler

et al. 2013

Journal of Vascular Surgery

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Vascular surgery has seen a revolutionary transformation in its approach to peripheral vascular disease over the last 2 decades, fueled by technological innovation and a willingness by the field to adopt these changes. However, the underlying pathology behind critical limb ischemia and the significant rate of unhealed wounds and secondary amputations despite apparently successful revascularization needs to be addressed. In seeking to improve outcomes, it may be beneficial to examine our approach to vascular disease at the fundamental level of anatomy, the angiosome, to better dictate reperfusion strategies beyond a simple determination of open vs endovascular procedure. We performed a systematic review of the current literature concerning the significance of the angiosome concept in the realm of vascular surgery. The dearth of convincing evidence in the form of prospective trials and large patient populations, and the lack of a consistent, comparable vocabulary to contrast study findings, prevent recommendation of the conceptual model at a wider level for guidance of revascularization attempts. Further well-structured, prospective studies are required as well as emerging imaging strategies, such as indocyanine green dye-based fluorescent angiography or hyperspectral imaging, to allow wider adoption of the angiosome model in vascular operations.

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“…[8][9][10] This angiosome model (called traditional angiosome in this project) divides the foot into three angiosomes: medial plantar, lateral plantar, and calcaneal angiosomes. These angiosomes are supplied by blood flow from medial plantar, lateral plantar, and medial calcaneal arteries, respectively.…”

mentioning

confidence: 99%

Oximetric angiosome imaging in diabetic feet

Zheng

Muccigrosso

Zhang

et al. 2016

Magnetic Resonance Imaging

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Purpose-To develop a noncontrast oximetric angiosome imaging approach to assess skeletal muscle oxygenation in diabetic feet.Materials and Methods-In four healthy and five subjects with diabetes, the feasibility of foot oximetry was examined using a 3T clinical magnetic resonance imaging (MRI) scanner. The subjects' feet were scanned at rest and during a toe-flexion isometric exercise. The oxygen extraction fraction of skeletal muscle was measured using a susceptibility-based MRI method. Our newly developed MR foot oximetric angiosome model was compared with the traditional angiosome model in the assessment of the distribution of oxygen extraction fraction.Results-Using the traditional angiosome during the toe-flexion exercise, the oxygen extraction fraction in the medial foot of healthy subjects increased (4.9 ± 3%) and decreased (−2.7 ± 4.4%) in subjects with diabetes (difference = 7.6%; 95% confidence interval = −13.7 ± 1.4; P = 0.02).Using the oximetric angiosome, the percent difference in the areas of oxygen extraction fraction within the 0.7-1.0 range (expected oxygen extraction fraction during exercise) between rest and exercise was higher in healthy subjects (8 ± 4%) than in subjects with diabetes (4 ± 4%; P = 0.02).Conclusion-This study demonstrates the feasibility of measuring skeletal muscle oxygen extraction fraction in the foot muscle during a toe-flexion isometric exercise. Instead of assessing oxygen extraction fraction in a foot muscle region linked to a supplying artery (traditional angiosome), the foot oximetric angiosome model assesses oxygen extraction fraction by its different levels in all foot muscle regions and thus may be more appropriate for assessing local ischemia in ulcerated diabetic feet.Foot disorders (such as ulceration, infection, and gangrene) are the leading causes of hospitalization in patients with diabetes mellitus (DM). 6 One key prognostic factor that is currently lacking in diabetic foot care is an accurate indicator of the local microvascular bed basal flow (skeletal muscle perfusion) and responsiveness (skeletal muscle oxygenation) to help guide diagnosis and intervention. HHS Public AccessThe angiosome concept, defined by Taylor and Palmer in 1987, 7 has been increasingly incorporated into endovascular procedures to treat patients with foot ulcers. [8][9][10] This angiosome model (called traditional angiosome in this project) divides the foot into three angiosomes: medial plantar, lateral plantar, and calcaneal angiosomes. These angiosomes are supplied by blood flow from medial plantar, lateral plantar, and medial calcaneal arteries, respectively. After identifying the artery responsible for perfusing the angiosome in which the ulcer is located, directed revascularization of that end-artery is undertaken to optimize healing. However, this angiographic angiosome may not be appropriate to address the local tissue perfusion that cannot be visualized by angiography, especially in patients with DM. 11 Furthermore, assessment of the effectiveness of the vascular ...

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Endovascular Treatment of Diabetic Foot in a Selected Population of Patients with Below-the-Knee Disease: Is the Angiosome Model Effective?

Cited by 65 publications

References 41 publications

The comparative efficacy of angiosome‐directed and indirect revascularisation strategies to aid healing of chronic foot wounds in patients with co‐morbid diabetes mellitus and critical limb ischaemia: a literature review

The comparative efficacy of angiosome‐directed and indirect revascularisation strategies to aid healing of chronic foot wounds in patients with co‐morbid diabetes mellitus and critical limb ischaemia: a literature review

Clinical implications of the angiosome model in peripheral vascular disease

Oximetric angiosome imaging in diabetic feet

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