Results of infrapopliteal endovascular procedures performed in diabetic patients with critical limb ischemia and tissue loss from the perspective of an angiosome-oriented revascularization strategy

Abstract

Our aim was to describe our experience with infrapopliteal endovascular procedures performed in diabetic patients with ischemic ulcers and critical ischemia (CLI). A retrospective study of 101 procedures was performed. Our cohort was divided into groups according to the number of tibial vessels attempted and the number of patent tibial vessels achieved to the foot. An angiosome anatomical classification of ulcers were used to describe the local perfusion obtained after revascularization. Ischemic ulcer healing and limb salvage rates were measured. Ischemic ulcer healing at 12 months and limb salvage at 24 months was similar between a single revascularization and multiple revascularization attempts. The group in whom none patent tibial vessel to the foot was obtained presented lower healing and limb salvage rates. No differences were observed between obtaining a single patent tibial vessel versus more than one tibial vessel. Indirect revascularization of the ulcer through arterial-arterial connections provided similar results than those obtained after direct revascularization via its specific angiosome tibial artery. Our results suggest that, in CLI diabetic patients with ischemic ulcers that undergo infrapopliteal endovascular procedures, better results are expected if at least one patent vessel is obtained and flow is restored to the local ischemic area of the foot.

Figure 1

Angiosomes of the foot. Calcaneal branch (1); medial plantar branch (2); and lateral plantar branch (3) of the posterior tibial artery; dorsalis pedis angiosome (4); anterior branch (5) and calcaneal branch (6) of the peroneal artery.

Figure 2

Ischemic ulcer healing at 12 months (a) and limb salvage at 24 months according to number of tibial vessels attempted for endovascular treatment. SR: single revascularization (Blue line); MR: multiple revascularization (red line). The standard error was <10% for the data shown.

Figure 3

Ischemic ulcer healing at 12 months (a) and limb salvage at 24 months according to number of patent tibial vessels achieved to the foot. Runoff 0 = none patent tibial vessel achieved (blue line); Runoff 1 = one patent tibial vessel achieved (red line); Runoff >1 = more than one patent tibial vessel achieved (black line). The standard error was >10% for the data shown in dashed lines.

Figure 4

Ischemic ulcer healing at 12 months (a) and limb salvage at 24 months according to an angiosome classification of the ulcers. IR: indirect revascularization without collaterals (blue line); IRc: indirect revascularization through collateral vessels (black line); DR: direct revascularization (red line). The standard error was >10% for the data shown in dashed lines.