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Published on: June 8, 2019
Indirect Endovascular Revascularization via Collaterals: A New Classification to Predict Wound Healing and Limb
Jenna C Bekeny1, Abdullah Alfawaz1, Jonathan Day2
1Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC.
Insights
Indirect revascularization via arterial connections improved lower extremity wound healing and amputation-free survival in chronic limb ischemia patients. This approach offers a valuable alternative when direct revascularization is not feasible.
Area of Science:
- Vascular Surgery
- Endovascular Therapy
- Limb Salvage
Background:
- Chronic limb ischemia often leads to lower extremity (LE) wounds requiring revascularization for healing and limb salvage.
- Direct revascularization of the source artery is preferred but not always achievable.
- Angiosome-directed revascularization strategies are crucial for treating these complex wounds.
Purpose of the Study:
- To evaluate the impact of arterial-arterial connections on clinical outcomes in patients undergoing angiosome-directed endovascular revascularization for LE wounds.
- To compare outcomes between direct revascularization (DR), indirect revascularization via collaterals (IR-C), and indirect revascularization (IR).
Main Methods:
- Retrospective review of consecutive patients with isolated infra-popliteal disease undergoing endovascular revascularization from 2012-2016.
- Classification of treatment into DR, IR-C (revascularization via collaterals), and IR (no direct or collateral source artery treatment).
- Collection and analysis of demographic data, comorbidities, and patient outcomes including wound healing and amputation-free survival.
Main Results:
- Wound healing rates were 80.0% (DR), 92.1% (IR-C), and 63.6% (IR) (P=0.009).
- Major amputation-free survival rates were 85.7% (DR), 89.5% (IR-C), and 69.7% (IR), with significant differences between IR-C and IR (P=0.036).
- Indirect revascularization via collaterals (IR-C) showed superior healing results compared to direct revascularization (DR) and indirect revascularization (IR).
Conclusions:
- Endovascular revascularization utilizing arterial-arterial connections, guided by the angiosome model, improves wound healing and amputation-free survival.
- Indirect revascularization via collaterals (IR-C) may offer superior outcomes, even in highly comorbid patients, serving as a viable alternative to direct revascularization.
- This study highlights the importance of considering collateral pathways in infra-popliteal disease management for limb salvage.
Background:
In the setting of chronic limb ischemia, lower extremity (LE) wounds require revascularization of source arteries for wound healing and limb salvage. Direct revascularization of the source artery is preferred but cannot always be performed. Our objective was to analyze the influence of arterial-arterial connections on clinical outcomes after angiosome-directed endovascular revascularization.
Methods:
Consecutive LE wounds in patients with isolated infra-popliteal disease revascularized endovascularly from 2012 to 2016 within a single center were retrospectively reviewed. Treatment was classified as direct revascularization (DR) if the source artery supplying the wound angiosome was treated, indirect revascularization via collaterals (IR-C) if the source artery angiosome was revascularized by another major artery via arterial connections, or indirect revascularization (IR) if direct revascularization of the source artery angiosome was not possible. Demographics, comorbidities, and patient outcomes were collected.
Results:
Of 105 patients with 106 LE wounds, there were 35, 38, and 33 patients in the DR, IR-C, and IR groups, respectively. The mean age was 65.8 years old (standard deviation (SD) 11.9) with 81 males (77.1%) and 24 females (22.9%). Average follow-up was 21.0 months (SD 14.0). Overall wound healing rates were 80.0%, 92.1%, and 63.6% for DR, IR-C, and IR, respectively (P = 0.009). Significant differences were found between all 3 group comparisons, DR versus IR-C (P = 0.010), DR versus IR (P = 0.013), IR-C versus IR (P = 0.008). Overall major amputation-free survival was 85.7%, 89.5%, and 69.7% in DR, IR-C, and IR groups, respectively, with statistically significant differences between the IR-C and IR groups (P = 0.036).
Conclusions:
Treating diseased infra-popliteal arteries and improving blood flow via arterial-arterial connections as per the angiosome model improved wound healing and amputation-free survival in this cohort. Although DR is still the gold standard, revascularization using IR-C may give superior healing results even in highly comorbid patients. This offers an additional avenue for treatment, especially when DR is not possible.
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