Angiosome-Targeted Infrapopliteal Angioplasty: Impact on Clinical Outcomes-An Observational Study

Abstract

Background: Revascularization based on the angiosome concept (AC) is a controversial subject because there is currently no clear evidence of its efficacy, due to the heterogeneity of patients (multiple and diverse risk factors and comorbidities, multiple variations in the affected angiosomes). Choke vessels change the paradigm of the AC, and the presence or absence of the plantar arch directly affects the course of targeted revascularization. The aim of this study was to evaluate the effect of revascularization based on the AC in diabetic patients with chronic limb-threatening ischemia (CLTI). Methods: This retrospective analysis included 51 patients (40 men, 11 women), with a mean age of 69 years (66-72) and a total of 51 limbs, who presented with Rutherford 5-6 CLTI, before and after having undergone a drug-coated balloon angioplasty (8 patients) or plain balloon angioplasty (43). Between November 2018 and November 2019, all patients underwent below-the-knee balloon angioplasties and were followed up for an average of 12 months. The alteration of microcirculation was compared between directly and indirectly revascularized angiosomes. The study assessed clinical findings and patient outcomes, with follow-up investigations, comparing wound healing rates between the different revascularization methods. Patient records and periprocedural leg digital subtraction angiographies (DSA) were analyzed. Differences in outcomes after direct revascularization and indirect percutaneous transluminal angioplasty (PTa) were examined using Cox proportional hazards analysis, with the following endpoints: ulcer healing, limb salvage, and also amputation-free survival. Results: Direct blood flow to the angiosome supplying the ulcer area was achieved in 38 legs, in contrast to 13 legs with indirect revascularization. Among the cases, there were 39 lesions in the anterior tibial artery (ATA), 42 lesions in the posterior tibial artery (PTA), and 8 lesions in the peroneal artery (PA). According to a Cox proportional hazards analysis, having fewer than three (<3) affected angiosomes (HR 0.49, 95% CI 0.19-1.25, p = 0.136) was associated with improved wound healing. Conversely, wound healing outcomes were least favorable after indirect angioplasty (p = 0.206). When adjusting the Cox proportional hazard analysis for the number of affected angiosomes, it was found that direct drug-coated angioplasty resulted in the most favorable wound healing (p = 0.091). At the 1-year follow-up, the major amputation rate was 17.7%, and, according to a Cox proportional hazards analysis, atrial fibrillation (HR 0.85, 95% CI 0.42-1.69, p = 0.637), hemodialysis (HR 1.26, 95% CI 0.39-4.04, p = 0.699), and number of affected angiosomes > 3 (HR 0.94, 95% CI 0.63-1.39, p = 0.748) were significantly associated with poor leg salvage. Additionally, direct endovascular revascularization was associated with a lower rate of major amputation compared to indirect angioplasty (HR 1.09, 95% CI 0.34-3.50, p = 0.884). Conclusions: Observing the angiosomes concept in decision-making appears to result in improved rates of arterial ulcer healing and leg salvage, particularly in targeted drug-coated balloon angioplasty for diabetic critical limb ischemia, where multiple angiosomes are typically affected.

Keywords: angiosome concept; critical limb-threatening ischemia; diabetes; drug-coated balloon; percutaneous transluminal angioplasty.

Figure 1

Wound healing depending on the type of angioplasty; p < 0.01.

Figure 2

Evolution of leg salvage depending on the type of angioplasty; p < 0.05.

Figure 3

Amputation-free survival depending on the type of angioplasty; p < 0.01.

Figure 4

WIfI classification according to the type of angioplasty in our observed groups.

Figure 5

Wound healing; p < 0.05.

Figure 6

Leg salvage; p < 0.01.

Figure 7

Survival without amputation; p < 0.05.

Figure 8

Clinical aspect.

Figure 9

Hallux amputation, excisional debridement, vacuum-assisted closure (VAC) placement.

Figure 10

Unfavorable evolution post-transmetatarsal amputation.

Figure 11

Aspect after excisional debridement and VAC therapy.

Figure 12

Angioplasty with SFA stent at the origin.

Figure 13

Pre and post SFA balloon PTa.

Figure 14

ATA balloon PTa.

Figure 15

Secondary suture post-Chopart amputation.

Figure 16

Follow-up at 2 weeks.

Figure 17

Follow-up at 3 weeks.

Figure 18

Follow-up at 3 months.

Figure 19

1-year Follow-up.

Figure 20

Clinical aspect on admission; Affected angiosomes—dorsal angiosome—ATA and lateral calcaneal angiosome—Peroneal artery.

Figure 21

Pre and post SFA balloon PTa.

Figure 22

Below-the-knee amputation.

Figure 23

1 year Follow-up.