Contributions of the Angiosome Concept in the Management of the Ischemic Diabetic Foot

ABSTRACTBackgroundTo evaluate the eventual clinical benefit of wound targeted revascularization (WTR) guided by the angiosomes concept (AC) in ulcer healing, limb preservation, and survival for primary below-the-knee angioplasties, in a seven-year prospective homogeneous registry of diabetic neuro-ischemic, Rutherford 5, Wagner 2-4 foot ulcers.MethodsFrom April 2009 to November 2016, a series of 188 limb-threatening neuro-ischemic foot wounds in 160 diabetic patients (70% men), mean age 71.9 years were prospectively recorded and scheduled for infragenicular endovascular treatment. Improved wound healing was the primary endpoint for treatment. Wound targeted revascularization (WTR) by primary endovascular approach following the AC direct branches and/or appended collateral network was attempted in each presentation. In cases in which first WTR direct approach (Group A /n=113 limbs) proved technically unachievable, either alternative WTR via collaterals (WTRc, or Group B /n=28 limbs), or compulsory wound indifferent revascularization (WIR, or Group C /n=35 limbs) for limb salvage were undertaken. ResultsThe global wound-targeted revascularization technical achievement (Groups A and B) following the AC (with or without mediation by regional collaterals) was 75%. Among these groups direct angiosomal “source-artery” revascularization (WTR) was feasible in 113 (60%) of the treated limbs. Starting from a zero point for tissue recovery, healing rate was 80% (+/-7) at 12 months in the A, 78% (+/-13%) in the B, and 47% (+/-13%) in the C Group at the same time intervals. Healing comparison between Groups A and B was non-significant (p=0.087, HR=1.47) while comparing the A with the C Group (p=0.0081, HR=0.44), and the B with the C Group (p=0.0005, HR=0.30), significant differences became apparent. The major adverse limb events (MALE) and limb salvage characteristics between A and B (p=0.027, and p=0.035), and A versus C Groups (p=0.0068, and p=0.0061) also appeared significant. Same parameters comparison between B and C cohorts yet showed no meaningful differences (p=0.959, and p=0.756). No dissimilarities in survival were observed. Conclusion WTR for diabetic neuro-ischemic foot ulcers appears to improve healing rates, when technically achievable. Although without uniform superiority, limb salvage and MALE seemed enhanced by direct revascularization, while no statistical difference emerged for survival. WIR remains an alternative option for limb preservation in about one quarter of patients.