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patient is started on antiplatelet therapy and heparin infusion. If the limb is viable or
marginally threatened, then endovascular intervention is the treatment of choice. Multiple
endovascular techniques are available (catheter-directed thrombolysis, rheolytic
thrombectomy,mechanicalaspirationthrombectomy).Inpatientswithsuprainguinalorpurely
embolicocclusionswithsignificantneurologicimpairment,surgeryispreferredifthepatient
isalowsurgicalrisk.
CriticalLimbIschemia
CLIisrecognizedbythepresenceofischemicrestpainandlesionsorgangreneattributableto
arterialocclusivediseaseformorethan2weeks.Itisalsorecognizedwithanklepressureless
than50mmHgortoepressure<30mmHginmedialcalcinosisorischemiclesionswithan
anklepressure<70mmHgandtoepressure<50mmHg.Atranscutaneouspartialpressureof
oxygenoflessthan30to50mmHgalsoaidsintheCLIdiagnosis.CLIpatientspresentwith
resting lower extremity pain, which is relieved temporarily by narcotics, and the patient
preferstodangletheirlegsdown.Themorefrankpresentationsaregangreneandulcers.The
usualfindingsofCLIincludeweakorabsentpulsesinthefeet,coolerfeet,dependentpallor,
poor growthoftoe nails, decreased hair growth onthelegs,darkdiscolorationofthe toes,
gangreneoftoes,soresorwoundsorulcersonthetoes,feet,orthelegsthathealslowlyordo
notheal.17 The ABI is usually ≤0.4, ankle systolic pressure ≤50 mm Hg, and toe systolic
pressure≤30mmHg.Microcirculationstudiesfromtheskinrevealacapillarydensityofless
than20 mm2,absentreactivehyperemiaon capillarymicroscopy,andtranscutaneousoxygen
tensionoflessthan10mmHg.OneyearafterthediagnosisofCLI,25%wouldhavediedand
30%wouldhaveundergoneamajoramputation.PatientswithchronicCLIhavea3-yearlimb
loss rateofapproximately40%. CLIpatients havea quality-of-life indexsimilar to thatof
patientswithterminalcancer.Thereisanunacceptablyhighrateofamputationifaggressive
revascularizationstrategiesarenotsought.Goodneyetal.18studied20,464patientswithCLI
and found that 54% of the patients had no diagnostic or therapeutic vascular procedures
performed in the year before the amputation. In another study, which used the Medicare
registry,theauthorsfoundthatamongthe417patientswhounderwentatleastoneinfrainguinal
amputation,only35%hadanABIand16%underwentangiographybeforeprimaryamputation.
Sixty-sevenpercentofthesepatientsunderwentprimaryamputationandonly33%underwent
someformofrevascularizationprocedure(23%underwentbypasssurgeryand10%underwent
balloonangioplasty) before undergoing anamputation. Majorityofthewound complications
(80%), MI (77.7%), stroke(81.2%), and death (100%) occurred intheprimaryamputation
group.
19
TREATMENT
Thegoals oftherapyinPADinvolve thefollowing:(1)improvethe patient’ssymptomsand
qualityoflife;(2)preventionandmanagementofgangrene,wounds,andulcersrelatedtoPAD;
(3)aggressiveprimaryandsecondarypreventionofcoronaryandcerebrovasculardisease.A
multidisciplinaryteamapproachisstronglyadvisedinPADmanagement.
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GLOBALRISKFACTORMODIFICATIONANDLIFESTYLE
CHANGES
SMOKINGCESSATION
Cigarette smoking along with diabetes is most strongly correlated with PAD. Smoking
cessationimprovesthe outcomesassociatedwithPADand systemic atherosclerotic disease.
Smokingcessationimprovedsymptomswithclaudicantby40%at10monthscomparedwith
patients whofailed to quitsmoking. Smoking cessationor a reductionimproved the3-year
survival(from40%to65%)inpatientsundergoingvascularsurgeryforPAD.
20
DIABETESMANAGEMENT
The American College of Cardiology (ACC)/AHA/American Diabetic Association (ADA)
guidelinesrecommendthatdiabeticsachievea hemoglobinA1Cgoalof<7.0%toreducethe
frequency ofcardiovascular complications andalso to help in retarding the progression of
PAD.21Podiatristsplayakeyroleinthesediabeticpatientsinthepreventionofdiabeticfoot
ulcersandearlytreatmentifitoccurs.Meticulousfootcarewithregularfootexaminationand
appropriatefootwearasapreventionstrategyisofutmostimportance.Thus,podiatristsplay
anindispensableroleinachievingthisfootcare,andalsothetimelyreferralofthesepatients
tovascularspecialistsimproveslimbsalvagerates.TheLEAP(LowerExtremityAmputation
Prevention)studywasdonetodeterminethecost-effectivenessoflowerextremityamputation
preventionstrategycomparedtostandardclinicalpracticeindiabeticpatientswithCLI.The
mainaimoftheLEAPstrategywastoenhancesalvageviaaggressiverevascularization.The
studyenrolled388patientsintheLEAParmandtheywerefollowedfor4years.TheLEAP
armhadacostsavingsofapproximately2,000dollarsperpatient.Also,theLEAPstrategyhad
loweramputationrates(29%vs.76%),lowerdeathrates(1%vs.19%),andfewerin-hospital
days(18vs.23days)whencomparedtostandardpractice.
22
HYPERTENSIONMANAGEMENT
AggressivecontrolofhypertensiontoachieveatargetBPof<140/90mmHgandamorestrict
goal of <130/80 mm Hg in diabetics and patients with renal insufficiency is highly
recommended.IntheHOPE(TheHeartOutcomesPreventionEvaluationStudy)trial,ramipril
reduced the risk of MI by 22% in patients with PAD. Beta-blockers were once thought to
worsenclaudication,butthishasnotbornetrueinlargestudies.Therefore,patientswithheart
diseasewhoarealreadyonβ-blockersshouldcontinuetobeonitunlessadvisedagainstitby
thepatient’scardiologists.
CHOLESTEROLMANAGEMENT
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Lipid-loweringtherapywithastatintoachieveatargetlow-densitylipoprotein(LDL)of<70
mgperdLisstronglyadvocatedbytheACC/AHAprofessionalsocietiesinpatientswithPAD
andthosewhohavehadanMI.Infact,eveniftheLDLis<70mgperdL,patientswithPADor
any form of atherosclerotic disease should be started on a statin.Among 6,748 individuals
withPADintheHeartProtectionStudy,theuseofsimvastatinreducedtheoverallmortalityby
12%,vascularmortality by17%,adversecoronaryeventsby24%, andstrokeby27%(ata
meanfollow-upof5years).Also,lipidloweringimprovesclaudicationsymptomsandextends
walkingtimes.
ANTIPLATELETTHERAPY
Antiplatelet therapyreceives a class IrecommendationintheACC/AHA guidelinesforthe
prevention of adverse cardiovascular events in PAD. The Antithrombotic Trialists’
Collaboration studied 42 clinical trials comprising9,214patients with PADandfound that
patientswhowereonantiplatelettherapyhad a 25% reductionin therateof stroke,MI,or
cardiovasculardeathwhencomparedwithpatientswhohadreceivedplacebo.TheACC/AHA
guidelines give the use of aspirin in PAD a class IA recommendation. The CAPRIE
(clopidogrel vs. aspirin in patients at risk of ischemic events) trial, which studied 19,000
patients, found that, individuals taking clopidogrel had an 8.7% relative reduction in the
composite endpoint ofMI, stroke, or vascular death when compared to those taking aspirin
alone.ThiseffectwasmorepronouncedinthesubgroupanalysisofpatientswithPAD,where
thecompositeendpointwasreducedby23.8%amongindividualstakingclopidogrel.Inlight
ofthesefindings,theACC/AHAandTASC-II(Trans-AtlanticSociety-II)guidelines23support
theuseofclopidogrelmonotherapyasanalternativetoaspirininpatientswithPAD(classIB
recommendation). The role of dual antiplatelet is not validated in any large trials. Dual
antiplatelettherapyisrecommendedinPADpatientswhoundergoanintervention.Usually,for
a month, and in patients who receive a drug-eluting stent (Zilver PTX stent), the dual
antiplatelettherapyneedstobecontinuedforatleast3months.Itisimportanttobemindful
thatpatientswithCADwhohavestentsinthemneedthedualantiplatelettherapyforatleast1
year(especiallyiftheyhavedrug-elutingstents).
EXERCISETHERAPY
Supervised exercise therapy along withcilostazol is themainstaytherapyforpatients with
intermittentclaudication.Variousmechanismshavebeenproposedonhowexerciseimproves
claudication,includingcollateralvesselangiogenesis,decreasedinflammation,decreasedfree
radical and lactic acid accumulation, better exercise pain tolerance, improved cellular
metabolism,efficientmuscleenergymetabolism,reducedblood viscosityand redbloodcell
aggregation, and improved endothelial function. The recommendations are for three to five
supervised exercise sessions per weekwith35 to50 minutes of exercise per session ona
treadmill (to achieve near-maximal claudication pain) for more than 6 months. In a metaanalysis of21 studies involving supervised walkingprograms, themeanwalkingdistanceto
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onset of claudicationwas increased by 180%. They also showed that the absolute walking
distancewasimprovedby130%whencomparedwithbaseline.
24,25
Itisimportanttonotethat
the exercise program has to be supervised. Studies have shown that unsupervised exercise
programs do not help the patients. Currently, supervised exercise program has a class IA
recommendationforthemanagementofintermittentclaudication.
DRUGTHERAPYFORCLAUDICANTS
Two medications that are approved by the Food and Drug Administration (FDA) for
claudicationmanagementarecilostazolandpentoxifylline.Cilostazolisaphosphodiesterase
inhibitor (PDE-3) that promotes vasodilatation andinhibits platelet aggregation. In clinical
trials, cilostazolstatistically improved thewalking distance after 12 weeksoftherapy. The
ACC/AHA and TASC-II guidelines recommend theuse of cilostazol for the management of
intermittent claudication in combination with supervised exercise therapy (class IA
recommendation).Itisimportanttobearinourmindsthattheuseofcilostazoltherapyhasa
blackboxwarningfromtheFDAinpatientswithcongestiveheartfailure.26Inameta-analysis
of11clinical studies,pentoxifyllineshowed onlymodest improvementinwalking distance.
Thisagentexertsitsbeneficialeffectsbyloweringbloodviscosityandimprovingredblood
cell flexibility. Pentoxifylline receives a class IIb recommendation for the management of
intermittentclaudicationasperACC/AHAandTASC-IIguidelines.
27
REVASCULARIZATIONTHERAPY
Revascularization therapy can be performed by either the endovascular or surgical route.
Recently, there has been tremendous improvement and introduction of several new
endovasculartechniques.RevascularizationremainsthecornerstoneoftreatmentforCLI.Itis
also indicatedinclaudicationforsymptom reliefforthosewhofailmedicaltherapyandthe
exercise program, and performed to reduce the level of amputation. The choice between
endovascular and surgical revascularization should be individualized.Each of the therapies
hasitsownmeritsanddemerits.
Based on the TASC-II classification, the vascular society has come up with guidelines
regardingthechoiceofrevascularizationtherapies.Thechoiceofrevascularizationtherapyis
dependentonthecomplexityandextentofPAD.TASC-IIclassificationispurelybasedonthe
anatomyofthedisease. There are two TASC classifications. Oneclassificationis for iliac
diseaseandtheotherclassificationisforfemoropoplitealdisease.Theclassificationisbased
on the location and severity of the stenosis, the length of the stenosis, number ofstenosis,
calcification, chronic total occlusions, level of reconstitution, prior endovascular
interventions,etc.TypeAisthe simplestlesionandtypeDisthemostcomplexlesion.The
societyrecommendsendovasculartherapyasthetreatmentofchoicefortypeAandBlesions
andsurgicaltherapyasthetreatmentofchoicefortypeDlesions.Surgicaltherapyispreferred
fortypeClesions.InadditiontothecomplexityandextentofPAD,thepatient’scomorbidities,
patient preference, available resources and expertise, along with the operator’s long-term
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successratemustbeconsideredaswellwhenmakingthetreatmentdecisionsfortypeCandD
lesions.With surgical approach,theriskofMIis 1.9% to 3.4%, mortality is 1.3% to6%,
wound infection is 10% to 30%, and scar-related neuropathic pain is 23%. About 30% of
graftswill require revision duringtheir lifetime. Endovascular treatmentis associated with
groin complications, contrast-related adverse reactions, risks associated with radiation
exposure,restenosis, andrepeatprocedures.Thefieldofendovasculartherapyis sorapidly
evolvingthatguidelinesandconsensusstatementsareyettoincorporatethesenewadvances.It
is suffice to say that the choice of revascularization therapy is dependent on the disease,
patient,andtheexpertiseavailable.
ENDOVASCULARTHERAPY
In the BASIL(bypassvs.angioplasty insevere ischemia oftheleg)trial, 452 patients with
severe chromic limb ischemia were randomized on an intention-to-treat basis to an initial
strategy of bypass surgery or endovascular treatment with angioplasty (not stenting) for
infrainguinal disease. Thisstudyshowed nosignificantdifferencesinthe outcomesbetween
theangioplastyandsurgerygroupsat3years.However,thisstudyhasbeencriticizedforbias
andthelackofuniformityinthestudypopulation.Also,thisstudywasdoneinanerawhere
endovascular techniques were still quite primitive in its evolution. Recently, studies have
demonstratedthatstentingofSFAlesionsyieldedabetterrestenosisandclinicalimprovement
whencomparedtoangioplasty only. In fact,onestudydemonstrated thatSFA stenting hada
24% restenosis rate at 6 months when compared to a 43% rate in those who underwent
angioplastyalone.Thus,thesefindingssuggestthatendovasculartherapyforSFAusingnitinol
stents may provide greater durability than angioplasty alone.28 In addition, with the
introduction of atherectomy debulking devices and drug-coated balloons (DCBs), the
endovascular specialistisable toachieve results similar tothatofstenting andthus hasthe
tremendousadvantageofnotleavingametalbehind.
PERCUTANEOUSTECHNIQUESANDTOOLS
Varioustools areavailableinthecurrenteratotreatPADby theendovascular route.These
include short and long angioplasty balloons, special cutting balloons, more recently FDAapproved DCBs, balloon-delivered and self-expandingstents, drug-eluting stents, debulking
atherectomy devices, reentry devices, and special crossing devices to cross chronic total
occlusions.
AngioplastyBalloonsandSpecialBalloons
There are several balloons available to treat PAD. Thestandard balloons come invarious
lengths, different profiles on the same balloon and can be complaint, semi-compliant, and
noncompliant (hence tailor-made for different kinds of lesions). Then we have the cutting
balloons,whichcanhavemetalspikes,metalwires,ormetalringswoundroundtheballoon.
Thesecuttingballoonsgiveanexcellentresultinresistant calcified lesionscausingminimal
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plaque shift, hence preserving side branches. The Chocolate percutaneous transluminal
angioplasty(PTA)ballooncatheter(Cordis,Fremont,CA)isanovelballooncatheterwitha
mountednitinol-constrainingstructurespecificallydesignedforuniformdilatationinresistant
lesions.TheChocolateballoonangioplastyregistrycontainsboth174patientswithabove-theknee(ATK) and180patientswith below-the-knee (BTK)lesions. In theATKcohorts, at6
monthspostintervention,only11%ofpatientsrequiredtargetlesionrevascularization(TLR),
96%ofpatientshadanamputation-freesurvival,and89%ofpatientswerefreeofanymajor
adverseevents.ThesuccessrateforBTKinterventionswasalsosimilarat3months,only7%
required TLR, theamputation-free survivalratewas 97%, andfreedomfrom major adverse
events was 90%. The othercuttingballoons are the AngioScore (AngioScore Inc, Fremont,
CA)andtheFlextome cuttingballoon(Boston Scientific, Marlborough,MA). DCBswill be
discussedinthesectionbelow.
Stents
There are several stents such as the Supera (Abbott vascular, Abbott Park, IL), EverFlex
(Covidien, Mansfield, MA), and Complete SE (Medtronics, Minneapolis, MN) that are
availableinthemarkettotreatPAD.Theonlydrug-elutingstentthatisavailableintheUSAis
Zilver PTX stent (Cook, Bloomington, IN) to be used in SFA lesions. The Zilver PTX
paclitaxel-elutingnitinolstent(ZilverPTXstent)trialenrolled60patientsandshowed90%
primarypatency ratesinZilverPTXgroupwhen comparedto52%primary patencyratesin
thePTAcontrolgroup(follow-upperiodof9months).Only8%ofallthepatientswhowere
treatedwiththeZilverPTXstentneededareinterventioninthefirst12months.
29,30
Drug-CoatedBalloons
Recently,DCBswereapprovedforitsuseinfemoropopliteallesionsbytheFDA.DCBsact
bydeliveringthe antiproliferative agenttothevessel wall without leaving anystentbehind.
Some of the advantages of the DCB are as follows: ability to treat bypass landing zones;
preserves the original anatomy of the vessel; does not leave a metal or polymer behind,
thereforeremovinganysourceforphysical,chemical,orimmunologictrigger;abilitytotreat
segmentswherestentsarenotadvised(commonfemoralandpoplitealarteries),andarecent
study showed that DCBs could potentiallylower theprojected budget impact over 2 years
whencomparedtostandardballoonangioplastyandbare-metalstentsastheyimproveprimary
patency and reduce target vessel revascularization (thus reducing the need for further
procedures).TheTHUNDER,FEMPAC,LEVANT,andPACIFIERtrialsshowedasignificant
reduction in late lumen loss (an objective means of assessing restenosis) and TLR when
comparedtostandardballoonangioplasty. Thesetrials andfew more recenttrials led toits
approval inthe management of femoropopliteal lesions by the FDA. DCBs have definitely
startedaneweraintheendovascularmanagementofPAD.
ATHERECTOMYDEVICES
Themajordisadvantageofangioplastyisrestenosis,whichmaybeovercometosomeextent
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bydebulkingtheplaque.Multiplestudieshaveshownadvantagesofthesedebulkingdevicesin
specificconditions.Therearefourdifferentkindsofatherectomy.
DirectionalAtherectomy
Directional atherectomy involves the resection of the atherosclerotic plaque with a cutting
device in the longitudinal plane. It is preferred in diabetic patients. Two FDA-approved
devicesare SilverHawkand TurboHawk(Covidien,Mansfield, MA).The DEFINITIVE-LE
(Determination of Effectiveness of the SilverHawk Peripheral Plaque Excision System
[SilverHawk Device] for the Treatment of Infrainguinal Vessels/Lower Extremities) trial
enrolled799patients(53%werediabetics)andfoundthatwithatherectomy,theywereableto
achieveaprimarypatencyrateof78%intheclaudicantand71%intheCLIgroupat1year
follow-up.31 There were no major differences in the results between diabetics and
nondiabetics.Additionally,theuseofDCBsafterdirectionalatherectomyincalcifiedresistant
lesionsyieldedexcellentresults.
OrbitalAtherectomy
This system employs a 360° rotational device with a diamond-coated crown that orbits
eccentricallywithinthevesselcontour.TheonlyFDA-approvedorbitalatherectomydeviceis
the CSIDiamondbackOrbitalatherectomysystem (CardiovascularSystems, Inc.,SaintPaul,
MN).TheCALCIUM360°(ComparisonofOrbitalAtherectomyplusBalloonAngioplastyvs.
BalloonAngioplastyAloneinPatientswithCriticalLimbIschemia)trialenrolled50patients
withheavilycalcifiedpoplitealorinfrapoplitealarteries,andtheyachievedaprimarypatency
rateof93%intheorbitalatherectomyarmwhencomparedto82%inthePTA-onlygroup.
32
The COMPLIANCE 360° (Comparing Balloon Angioplasty to Diamondback 360° Orbital
AtherectomySystem in Calcified Femoropopliteal Disease) studyenrolled 50 patients with
heavilycalcifiedfemoropoplitealvesselsandshoweda72.7%freedomfromTLRat6months
inthegroupthatreceived orbital atherectomyandPTAwhencomparedto8.3%inthePTA-
only group.33 Hence, orbital atherectomy is an excellent tool in calcified infrainguinal
femoropoplitealandinfrapopliteallesions.
RotationalAtherectomy
Rotational atherectomy employsa high-speed rotating cutting blade (or “burr”) coatedwith
abrasive material suchas microscopic diamondparticles andatthe same time aspirates the
denudedparticles.34 The FDA-approved device is Pathway PV system (currentlyJetstream;
Pathway Medical Technologies, Kirkland, WA). The single-arm Pathway PVD trial that
enrolled172patients(42%werediabetics)showedthat38.2%ofthepatientshadevidenceof
vesselrestenosis,and26% ofthe patientsunderwentrepeatTLR, whichis betterthan PTA
alone.35TheotherdevicesaretheRotablator(BostonScientific,Marlborough,Fremont,CA)
and the Phoenix atherectomy device (AtheroMed, Menlo Park, CA), which is still under
investigation.Thus,itisveryusefulinthetreatmentofcalcifiedlesions.
34
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LaserAtherectomy
Thistechniqueutilizeslasertoremoveatheroscleroticplaqueby“photoablation.”TheTurboBooster/Turbo-Elite laser catheter (Spectranetics, Colorado Springs, CO) is the onlyFDAapproved device for the treatment of femoropopliteal in-stent restenosis. The CELLO
(CliRpathExcimerLaserSystemtoEnlargeLumenOpenings)studyenrolled65patientsand
showed a primary patency of 54%.35 The EXCITE ISR (EXCImer Laser Randomized
Controlled Studyfor TreatmentofFemoropopliTEalIn-StentRestenosis) was a prospective
randomized multicenter study that compared excimer laser atherectomy (169 patients) with
standard balloonangioplasty (81 patients)forfemoropopliteal in-stentrestenosis. The laser
armhadsignificantlyhigherproceduralsuccessrateandsafetyrateandlower TLRthan the
standardballoonangioplastyarm.ItwasthisstudythatledtoitsapprovalbytheFDA.
CHRONICTOTALOCCLUSIONDEVICESAND
REENTRYDEVICES
Therearemanytoolsavailabletocrosschronictotalocclusions.Themostcommonlyusedare
the Viancecrossingcatheter(Covidien,Mansfield,MA),Crosser (Bard, Tempe,AZ), Laser
(Spectranetics,ColoradoSprings,CO),andTruePath(BostonScientific,Marlborough,MA).
Reentryintothetruelumendistallywhereitreconstitutescanbeachievedbydeviceslikethe
Pioneer(ultrasoundguided,Volcano,SanDiego,CA),Outback(fluoroscopyguided,Cordis,
Fremont, CA), Ocelot (optimal computed tomography [OCT] guided), and Enteer reentry
system(Covidien,Mansfield,MA).
SURGICALTHERAPY
Surgicaltherapyisdependentonthelesioncomplexity;patient’scomorbidities;availabilityof
venousconduits,adequatetargetdistalvessels,resources,expertise;andfinallythesurgeon’s
track record. As per Medicare claims data from 1996 to 2006, there has been a >3-fold
increase in endovascular intervention and bypass surgery decreased by 42%. Despite the
decreasing rate of bypass, surgery remains an important treatment strategy in advanced
multilevel vascular disease. Typically, surgical mode of revascularization is indicated in
patients with acceptable surgical risk (and life expectancy of >2 years) who need a more
durable long-lasting repair, those patients whose vascular disease cannot be managed by
endovascularstrategies,andfinallythosewhohavefailedendovasculartreatment.Therehas
tobe anadequate venous conduitavailable for bypass, otherwise the patency rates are the
sameasthoseforendovascularstrategies.Mortalityratesfromsurgeryrangefrom3%to8%
dependingonthecomorbidities.Ontheotherhand,theratesofmajorcomplicationsassociated
withendovascularinterventionsrangefrom1.9%to2.9%.Withtherisingelderlypopulation
and its concomitant cardiovascular comorbidities, endovascular intervention is usually the
preferredchoiceofrevascularization.Inthiscurrentera,severalpatientsmaybenefitfroma
hybridapproach,wheretheinflowistakencarebyoneapproachandtheoutflowviatheother
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approach,dependingonthearterialanatomy.
USINGTHEANGIOSOMEPRINCIPLEINPLANNING
THEOPTIMALREVASCULARIZATION
Successfullimbsalvageis dependentondetailed knowledgeofthe vascularanatomyof the
foot and ankle. The concept of angiosomes was first introduced in 1987 by Taylor and
Palmer.36 They divided the body into three-dimensional vascular territories supplied by
specificsourcearteriesanddrainedbyspecificveins.Thefootandanklearecomposedofsix
distinctangiosomes37;thesixangiosomesofthefootandankleoriginatefromthethreemain
sourcearteries.Theposteriortibialarterysuppliesthemedialankleandtheplantarfootwhich
includesthecalcanealbranch(heel),themedialplantarartery(instep),andthelateralplantar
artery(lateralmidfootandforefoot).Theanteriortibialarterysuppliestheanteriorankleand
thenbecomesthedorsalis pedisartery,whichsuppliesthe dorsumofthefoot. Theperoneal
artery supplies the anterolateral portion of the ankle and rear foot with two branches, the
anteriorperforatingbranch(lateralanteriorupperankle)andthecalcanealbranch(lateraland
plantar heel). Arterial–arterial connectionsallow for uninterruptedblood flow to the entire
foot despite the occlusion ofone or more arteries. The primarygoal for CLIpatients is to
reestablish pulsatile straight-line flow to the distal extremity, especially to the respective
angiosomewheretheulcerorgangreneispresent.38Unfortunately,15%ofsurgicalbypasses
fail to improve ulcer healing because they do not provide blood supply to the affected
angiosome.39 Gooden and colleagues found that up to 25% of patients with heel ulcers
ultimately succumbed to a proximal leg amputation despite a palpable pedal pulse.40 The
major reasonis inadequaterevascularization,becausethesupplyingarteryorthe collaterals
supplyingtheischemicareaareoccludedorabsent.41Thefailureratesofwoundhealingcan
be decreased if the bypassed vessel directly feeds the vessel that supplies the angiosome
whichisaffected(straight-lineflow),ratherthanrevascularizingoneoftheothertwovessels
thatmaysupplybloodviacollateralorarterialtoarterialconnections.42ClemensandAttinger
retrospectivelyexaminedthe resultsofdirect versusindirectrevascularizationof 52 limbs.
The direct revascularization group had fewer failures (9.1% vs. 38.1%) than the indirect
revascularization group. Those who failed to heal underwent major amputation. The
amputation rates were four times higher in the indirect revascularization group. There is
increasing evidence to support the use of angioplasty in CLI patients with infrapopliteal
disease.Onestudy,witha5-yearfollow-up,showedtibioperonealangioplastywaseffective
with a clinical success rate of 95%. Among those patients whohad a clinically successful
angioplasty,91%ofthoselimbsweresalvaged,only8%underwentbypasssurgeryandonly
9% neededsignificant amputations. Meta-analysisofinfrapoplitealangioplastybyRomiti et
al.43reported12-monthand36-monthresultsasfollows:primarypatencyratesat77.4%and
48.6%,secondarypatencyratesat83.3%and62.9%,limbsalvageratesat93.4%and82.4%,
andpatient survival rates at 98.3% and 68.4%, respectively. Despite the marginal patency
ratesat36months,thewoundhealingisbetterandisdefinitelyabetteroptionthanamputation.
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Table9-3.
Table9-4.
ANGIOSOMETERRITORIES
Tables9-3and9-4showtheareasuppliedbyinfrapoplitealarteriesanditsbranches(Fig.9-
2).
SURVEILLANCE
Asmentionedearlier,ABIsandduplexultrasonographyarethepreferredsurveillanceteststo
follow patientspostendovascular or surgical interventions.The benefitof surveillanceis to
improvetheprimaryassistedpatencyrates.Therecommendedsurveillanceoptionsfromour
experience are as follows. For iliac and BTK revascularization therapies, duplex
ultrasonography should beperformedat6 monthsandyearlythereafter.Forfemoropopliteal
andgraftinterventions,itshouldbeperformed every3monthsforayearandthen6 months
thereafter.
SiteofPaintoCulpritArterialObstruction
Heel Peronealorposteriortibialartery
Plantarfoot Posteriortibialartery
Lateralanklewound Peronealartery
Dorsalfoot Anteriortibialartery
AngiosometoCulpritArterialObstruction
TibialArteries AreasSupplied(angiosomes) BranchDistribution
Anteriortibialand
dorsalispedis
Anteriorlegandthedorsumofthefoot
Posteriortibial Insideoftheheel,soleofthefoot,plantarsurface,
andwebspacesoftoes
Heel—calcanealbranch
Instep—medialplantarbranch
Lateralmidfootandtheforefoot—lateral
plantarbranch
Peroneal Lateralankleandheel Plantaraspectofheel—calcaneal
branch
Anterolateralpartofupperankle—
anteriorperforatingbranch
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