Systematic Review and Meta-analysis of Direct Versus Indirect Angiosomal Revascularisation of Infrapopliteal Arteries

Abstract

Conclusions: These quality indicators will help clinicians to assess the appropriateness of healthcare provided in PAD. The development of evidence-based indicators in PAD is limited by the lack of methodological quality of the research in this disease, the inconclusiveness of the evidence on diagnostic and surgical techniques, and the dynamic nature of the vascular diseases field.

Preventing and treating foot complications associated with diabetes mellitus

“…[74][75][76] This tech nique is based on the three tibial arteries (that is, pero neal, anterior and posterior) supplying different parts of the foot, therefore, attempts to revascularize need to focus on supplying the vessel that best feeds the area where tissue loss has occurred, especially in the feet of patients with diabetes mellitus. [74][75][76] Indeed, some evidence sug gests that wound healing and limb salvage is improved 64 with this method, especially for angioplasty, 75,76 although valid criticisms, such as the retrospective nature of these studies, have been raised. 77 A comparison of healing between surgical and endo vascular revascularization techniques revealed that for large wounds, surgical bypass seems to achieve better wound healing than endovascular techniques, in terms of the proportion of patients healed and with a trend for quicker healing.…”

Commentary: Myths and Proofs of Angiosome Applications in CLI: Where Do We Stand?

“…4,15,16 In many authors' view, it stands as a logical guide to accurate anatomical and hemodynamic wound-directed reperfusion. 2,16 However, at the current level of knowledge regarding CLI mechanisms, even with better definitions of an effective direct revascularization procedure, 9,[19][20][21]30 do we really control all small microcirculatory changes 15,16,29 inside the macrovascular perfusion system that contains the angiosome level? 16 …”

Personalized Approach to Revascularization of Critical Limb Ischemia

“…A recent meta-analysis of 15 cohort studies found that angiosome-directed revascularization improved wound healing rates compared with indirect revascularization (odds ratio, 0.40; 95% confidence interval, 0.29-0.54), and also improved limb salvage rates at 1 year (odds ratio, 0.24; 95% confidence interval, 0.13-0.45). 5 Similarly, a second meta-analysis of 9 studies in which the vast majority of patients were diabetic found that angiosome-directed revascularization was associated with a lower risk of unhealed wound (hazard ratio, 0.64; 95% confidence interval, 0.52-0.80), and a lower risk of major amputation at 1 year (hazard ratio, 0.44; 95% confidence interval, 0.26-0.75). The results of the current study, therefore, should be viewed in the context of these studies.…”

“…Nevertheless, despite the current evidence, there are no randomized clinical trials comparing the angiosome-directed and indirect revascularization strategies. 4,5 Hence, although the angiosome concept makes intuitive sense, enthusiasm of 1 approach over another should be tempered until more definitive trials are conducted.…”