2007 Abstracts: Revascularization of a Specific Angiosome for Limb Salvage: does the Target Artery Matter?

Background: Ischemic wounds of the lower extremity can fail to heal despite successful revascularization. The foot can be divided into five anatomic regions (angiosomes) fed primarily by distinct source arteries arising from the posterior tibial (3), anterior tibial (1) and peroneal arteries (1). This study investigated whether bypass to the artery directly feeding the ischemic angiosome had an impact on wound healing and limb salvage.
Methods: Retrospective analysis was performed for 52 non-healing lower extremity wounds (48 patients) requiring tibial bypass over a two year period. Preoperative arteriograms were reviewed to determine arterial anatomy relative to each wound's specific angiosome as well as the anatomy of the bypass performed. Patients were then divided into two groups: direct revascularization (bypass to the artery directly feeding the ischemic angiosome) or indirect revascularization (bypass to an artery unrelated to the ischemic angiosome). There were no statistically significant differences in the co-morbidities of the two groups. Wound outcome was analyzed; complete healing, failure to heal leading to amputation, or death unrelated to wound. Time to healing was noted for the healed wounds.
Results: Based on preoperative arteriography, 51% (n=27) of wounds received direct revascularization (DR) to the ischemic angiosome, while 49% (n=25) underwent indirect revascularization (IR). Revascularization was by tibial bypass using saphenous vein (n=34, 65%) or PTFE with a distal vein patch (n=18, 35%). Bypasses were performed to the AT (n=22, 42%), PT (n=17, 33%), or peroneal (n=13, 25%) arteries based on the surgeon's judgment at the time of bypass. One bypass failed in the perioperative period. The remaining bypasses were patent at the time of final wound analysis. Due to 17% mortality during follow-up, 43 wounds were analyzed. This analysis showed that 77% (n=33) progressed to complete healing and 23% (n=10) failed to heal leading to 8 amputations. In the DR group there was 91% healing with a 9% amputation rate. In the IR group there was 62% healing with a 38% amputation rate (p=0.03). In those wounds which did heal, total time to healing was not significantly different; DR 162.4 days vs. IR 159.8 days (p=0.95).
Conclusion: Revascularization plays a crucial role in the treatment of ischemic lower extremity wounds. We believe that direct revascularization of the angiosome specific to the anatomy of the wound leads to a higher rate of healing and limb salvage. Although many factors must be considered in choosing the target artery for revascularization, consideration should be given to revascularization of the artery directly feeding the ischemic angiosome.