Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia

Blood supply to the foot is from the posterior tibial, anterior tibial, and the peroneal arteries. Ischemic ulceration of the foot is the most common cause for major amputations in vascular surgical patients. It can be presumed that revascularization of the artery directly supplying the ischemic angiosome may be superior to indirect revascularization of the concerned ischemic angiosome.

This was a prospective study of 64 patients with continuous single crural vessel runoff to the foot presenting with critical limb ischemia from January 2007 to September 2008. Direct revascularization (DR) of the ischemic angiosome was performed in 61% (n=39), indirect revascularization (IR) in 39% (n=25). Open surgery was performed in 60.9% and endovascular interventions in 39.1%. All patients were evaluated for the status of the wound and limb salvage at 1, 3, and 6 months. The study end points were major amputation or death, limb salvage, and wound epithelialization at 6 months.

In the study, 81.2% of patients had forefoot ischemia, 17.2% had ischemic heel, whereas 1.6% had midfoot nonhealing ischemic ulceration. The runoff involved the anterior tibial artery in 42.2% (27/64), posterior tibial artery in 34.4% (22/64), and the peroneal artery in 23.4% (15/64). All patients were followed at 1, 3, and 6 months postoperatively for ulcer healing, major amputation, or death. At the end of 6 months, nine patients expired, and six were lost to follow-up. Of 49 patients who completed 6 months, nine underwent major amputation, and 40 had limb salvage. Ulcer healing at 1, 3, and 6 months for DR vs IR were 7.9% vs 5%, 57.6% vs 12.5%, and 96.4% vs 83.3%, respectively. This difference in the rates of ulcer healing between the DR and IR groups was statistically significant (P=.021). The limb salvage in the DR group (84%) and IR group (75%) was not statistically significant (P=.06). The mortality was 10.2% for DR and 20% for IR at 6 months.

To attain better ulcer healing rates combined with higher limb salvage, direct revascularization of the ischemic angiosome should be considered whenever possible. Revascularization should not be denied to patients with indirect perfusion of the ischemic angiosome as acceptable rates of limb salvage are obtained.