Primary infragenicular angioplasty for diabetic neuroischemic foot ulcers following the angiosome distribution: a new paradigm for the vascular interventionist?

Abstract

The angiosome principle was first described by Jan Taylor in 1987 in the plastic reconstructive surgery field, providing useful information on the vascular anatomy of the human body. Specifically concerning foot and ankle pathology, it may help the clinician to select better vascular access and specific strategies for revascularization. This knowledge may be particularly beneficial when treating diabetic neuroischemic foot wounds associated with particularly aggressive atherosclerotic disease and a poor collateral circulation. The implementation of angiosome-based strategies in diabetic infragenicular vascular reconstruction may afford encouraging wound healing and limb preservation rates using both bypass and endovascular techniques. The minimal invasiveness of these novel strategies enables us to perform more specific and more distal tibial and/or foot arterial reconstructions, in one or multiple targeted vessels. This paper reviews the available literature on this revascularization strategy and focuses on the potential benefit of angiosome-guided primary angioplasty for diabetic ischemic foot ulcers.

Keywords: angioplasty; angiosomes; critical limb ischemia; diabetic foot; limb salvage.

Figure 1

A simplified illustration of previously suggested angiosomes of the foot and lower ankle. Abbreviations: DP, dorsalis pedis artery angiosome; LP, lateral plantar artery angiosome; MP, medial plantar artery angiosome; LC, lateral calcaneal artery angiosome; MC, medial calcaneal artery angiosome.

Figure 2

Selective revascularization of the posterior tibial and lateral plantar artery angiosome: (a–f) Staged angioplasties in the posterior tibial artery. (g–i) Selective angioplasties in the lateral plantar artery and its appended angiosome.

Figure 3

Clinical correspondence of the angiographic pattern showed in Figure 2. A neuroischemic plantar ulcer in an acute diabetic foot presentation: (a) Initial clinical aspect featuring a lateral plantar artery hypoperfusion and sole forefoot abscess. (b) and (c) Abscess drainage and debridement. (d) and (e) Clinical evolution at weeks 3 and 5.

Figure 4

Selective revascularization of the distal posterior tibial artery and its appended medial plantar artery angiosome. (a) and (b) Selective angioplasty in the posterior tibial artery, and (c) and (d) specific revascularization of the medial plantar artery and its angiosome.

Figure 5

A right hallux neuroischemic sole ulceration matching the angiographic features showed in Figure 4. There is medial plantar artery hypoperfusion in an end-artery occlusive disease pattern for the first toe. (a) Initial presentation and (b) clinical evolution at 1 month after angioplasty. (c) Results 2 months later.

Figure 6

Global medial and lateral plantar artery critical ischemia and acute diabetic foot syndrome matching staged occlusions in the posterior tibial artery (with end-artery occlusive disease model to the sole). (a) Prime posterior tibial artery staged subocclusive lesions. (b) and (c) The reestablished flow in the posterior tibial and both right plantar arteries. (d) The initial clinical aspect. (e) Subsequent evolution at 3 weeks. (f) Clinical results after 5 months of team surveillance.

Figure 7

Selective anterior tibial and related dorsalis pedis artery angiosome: (a–c) Primary staged anterior tibial angioplasty, (d) initial dorsal foot ulceration, (e) clinical results at 1 month following (f–h) associated dorsalis pedis selective angioplasty.

Figure 8

Specific posterior tibial and adjacent medial calcaneal artery angiosome revascularization in heel related wound. (a) Tight stenosis in the distal posterior tibial artery, above emergence of the medial calcaneal branch, (b) Angiographic result after selective angioplasty, (c) initial presentation of heel ulcer, and (d) clinical results after 5 weeks of team surveillance.

Figure 9

Lateral calcaneal artery and peroneal main flow-related angiosome ulceration. (a, b) Initial pattern of perfusion featuring the peroneal artery as single and severely diseased (end-artery occlusive model) calf vessel, (c) re-established flow in the peroneal territory, (d) prime aspect of lateral calcaneal and inframalleolar tissue defect, and (e–g) subsequent clinical evolution at weeks 1, 5, and 6.