1. Combien y-a-t’il d’angiosomes
dans le pied?
1. 2. 3. 4.
14% 14%
5%
68%
1. 3 (un pour chaque vaisseau dans le pied)
2. 6
3. Entre 8 et 12, tout dépend de la pointure
des chaussures
4. Plus de 40

2. Ce concept d’angiosome...
1. 2. 3. 4. 5.
4%
0%
76%
16%
4%
1. Aide à localiser une ligne d’incision
sécuritaire
2. Aide à déterminer un niveau d’amputation
3. Est utile dans la construction d’un lambeau
pédiculé
4. Aide à choisir le site de l’anastomose distal
lors de reperfusion du pied
5. Toutes ces réponses

3. Michel Legault M.D., FRCS, FACS
Division of Vascular Surgery
Centre Hospitalier Régional De Lanaudière
Joliette, Québec
Association des Chirurgiens Vasculaires du Québec
Quebec city, May 23rd 2014.

4. PLAN
1. ANATOMY OF FOOT ANGIOSOMES
2. PHYSICAL EXAM.
3. THE CLINICAL CONCEPT
4. A LOOK AT SOME RELEVANT STUDIES
5. WHAT SHOULD WE LEARN FROM THIS
CONCEPT

5. ANATOMY
 Ian Taylor’s anatomic study (1987)
 Three-dimensional blocks of tissue fed by « source »
arteries (40 angiosomes in the body)
 The foot is composed of 5-6 angiosomes (from the
three main arteries of the leg)
 Choke vessels (arterial-arterial connections)

6. ANATOMY POST. TIB.
 1. calcaneal branch
o Medial ankle
o Plantar heel
 2. medial plantar
o Medial forefoot
 3. lateral plantar
o Lateral forefoot
 PERONEAL
 4. anterior branch
o Anterior upper ankle
 5. calcaneal branch
o Lateral ankle
o Plantar heel
 ANT. TIB.
 6. dorsalis pedis
o Dorsum of the foot

11. PHYSICAL EXAM

19. CLINICAL CONCEPT
 Why vascular surgeons have some interest of this
concept?
 Major amputation
 Heel ulcer
 25% of pts with heel ulcer (Ruth 5-6) will have a
proximal leg amputation despite a palpable pedal
pulse (Mills, am.j.surg., 1997)
 15% of bypasses fail to heal the foot (Ruth 5-6) despite
remaining patent (Pomposelli, JVS, 1999)

20. CLINICAL CONCEPT
 Diab. Foot ulcer (Faglia, Diabetes care, 2009)
 Major amput. > 50% at 5-year f-up if no revasc procedures
 If there is  8 to 20% risk of major amput. at 5 years
 A dorsalis pedis bypass is unlikely to heal a heel ulcer if the
lateral plantar artery is thrombosed
 Current literature suggests that the peroneal artery is an
acceptable vessel for revasc. , with patency, limb salvage,
and healing rates that are comparable to ant. tib. and post.
tib. arteries.
 (Sneider, JVS, 1993)
 (Darling, am.j.surg. , 1995)
 (Abou-Zamzam, arch.surg, 1996)

21. CLINICAL CONCEPT
 The natural anastomosis between angiosomes may
be incomplete or inadequate.
 Does the angiosome concept apply to pts with CLI ?
 The angiosome concept has had profound impact
on the development of strategies for plastic and
reconstructive surgery. However, only little attention
has been paid to the angiosome model in treatment
of CLI.

22. CLINICAL CONCEPT
 A direct bypass ( to a major vessel supplying the angiosome
of the ulcer) will have better chance to heal the wound
than an indirect bypass. (Attinger, Plast.Reconst.Surg. ,
2006)
 Wound healing of heel ulcer is possible even in the absence
of an intact pedal arch, thus relying on either the intact
pedal arch or interangiosome connections for perfusion
(choke vessels). (Pomposelli, JVS, 1999)
 The choke vessels need a period of ischemia to open (4 to
10 days).

23. STUDIES
 Pomposelli, JVS, 1999
 Retrospective
 D.P. bypasses for heel ulcer vs. forefoot ulcer
 Heel ulcer
o Complete healing = 86%
o Major amput. = 9%
 Forefoot ulcer
o Complete healing = 90%
o Major amput. = 9%
 Pts with heel ulcer who have had a D.P. bypass have adequate
heel perfusion irrespective of a patent pedal arch.

24. STUDIES
 Treiman, JVS, 2000
 Retrospective
 81 pts with non-healing heel wounds (Ruth5-6)
 34 fem-pop, 40 fem-tib, 7 distal bypasses
 73% granulation
 11% major amput.
 Variables predictives of heel ulcer healing were
o Patent post. tib. beyond ankle
o Normal renal function
o Palpable pedal pulse

25. STUDIES
 Attinger, AM.J.Reconst.Micorsurg, 2001
 Retrospective
 60 distal bypasses for ischemic ulcers (Ruth5-6)
 50% direct revasc / 50% indirect revasc
 9% failure rate for direct revasc
 38% failure rate for indirect revasc

26. STUDIES
 Neuville, Ann.Vasc,Surg, 2009
 Retrospective
 Distal bypass only
 27 direct revasc / 25 indirect revasc
 91% healing and 9% amupt. in direct vs. 62% and 38% in
indirect (p=0.03)
 Wound characteristics and infection were not reported

27. STUDIES
 Lida, Cardiovasc.Interv. , 2010
 Retrospective
 Endovasc treatment of 203 limbs with CLI. (Ruth5-6)
 86% limb salvage at 1 year in direct revasc vs. 69% in
indirect revasc (p=0.03)
 Elevated levels of C-reactive protein were found to be
independant predictors of major amput. in the indirect
revasc group, but not in the direct group.

28. STUDIES
 Varela, Vasc.Endovasc.Surg. , 2010
 A mixed cohort of venous bypass and PTA
 Looked at the prognostic significance of indirect revasc via
collaterals
o Between distal calcaneal peroneal branches and ant. or post. tib.
(n=16)
o Between patent pedal arch connecting dorsal and plantar blood
supply (n=2)
 92% wound healing rate at 1 year for indirect group
 88% wound healing rate at 1 year for direct group
 When including indirect revasc without visible collaterals, the
wound healing rate at 1 year was 73% (p=0.008)

29. STUDIES
 Deguchi, J.Japan.Coll.Angiol. , 2010
 Retrospective
 Surgical bypass only
 No difference in wound healing time or limb salvage
between 2 groups
 Small numbers
 Limited statistical strength

30. STUDIES
 Blanes Orti, Angiologia, 2011
 Retrospective
 PTA only
 No difference in wound healing time or limb salvage
between 2 groups
 Small numbers
 Limited statistical strength

31. STUDIES
 Azuma, Eur.J.Vasc.Endovasc.Surg. , 2012
 249 distal bypasses ; 81% diabetic, 49% ESRD
 No difference in the healing rate between 2 groups
(p=0.185)
 Healing rate was slower in pts with ESRD in the indirect
group (p<0.001)
 The angiosome concept seems unimportant, at least in
non-ESRD cases

32. STUDIES
 Alexandriescu, J.Cardiovasc.Surg. , 2012
 Retrospective
 Review their cases of PTA and bypasses before and after
2005 for Ruth5-6 (when they introduced the angiosome
concept in their practice).
 Significantly better wound healing rate in the direct
group
 Probably biased by the general learning curve of the
group

33. STUDIES
 Alexandriescu, Scand.J.Surg. , 2012
 Retrospective
 50% direct / 50% indirect (2008-2011)
 PTA and bypasses
 74% of the wounds have healed within 1 year in the
direct group
 46% of the wounds have healed within 1 year in the
indirect group (p=0.002)

34. STUDIES
 Rashid, JVS, 2013
 The impact of direct angiosome revasc on the healing of
ischemic foot tissue lost in relation to the quality of the
pedal arch
 Based on DSA
o Complete pedal arch (CPA)
o Incomplete pedal arch (IPA)
o No pedal arch (NPA)
 148 distal bypasses (Ruth5-6)
 46% direct group / 54% indirect group
 CPA (22%), IPA (62%), NPA (16%)

35.  Healing rate of foot tissue lost was significantly
influenced by the quality of the pedal arch rather than
the angiosome revascularized.

36. DISCUSSION
 According to the angiosome model, the specific feed artery,
rather than the « best vessel », should be favoured for
revasc.
 Attractive concept. In accordance with pathophysiological
knowledge.
 In line with experience from coronary bypass surgery,
where reperfusion through collaterals does not provide a
similar freedom from cardiac events.
 It may provide the rationale for endo. vs. open repair
according to which target artery is accessible by which
method.

37. DISCUSSION
 All of the studies are retrospective
 More often than not, the angiosome specific
artery will also be the most diseased artery
and the ability to recanalize this vessel will
most probably select the least
atherosclerotic pts to the « direct revasc
group ».

38. CONCLUSION
 As evidence stands at the moment, there is some, although
limited, evidence that when there is a choice of target
artery for revasc, preference should be given to the artery
directly feeding the wound’s angiosome.
 The effect of direct revasc may especially be relevant in the
settings of
 End stage renal failure
 Infected wounds
 Endovasc rather than surgical repair
 In case where collaterals are absent
 Prospective collected data are needed