Applicability of Intentional Topographic Revascularization Following the Angiosome Model in Patients with Chronic Limb-Threatening Ischemia: From Theory, to Current Clinical Challenges

Abstract

Since its first description almost four decades ago in the plastic surgery field, the angiosome theory has shown encouraging clinical success in Chronic Limb-Threatening Ischemia (CLTI) revascularization in recent years. Gradual scientific knowledge and evidence-based feedback are necessary to assess its usefulness and to overcome various challenges lingering in its practical application at the patient’s bedside. Despite the increasing number of publications in recent years indicating its acceptable suitability in clinical practice, only a few provide conspicuous information regarding the applicability of angiosome-guided Direct Revascularization (DR) compared with the analysis of hurdles in the vascular approach, regardless of its clinical results. The current review aimed to provide an updated interpretation of DR applicability rates in daily practice, delineated through tangible assessments of feasibility, clinical match, and technical success (as previously mentioned). This analysis considered the applicability of DR, Indirect Revascularization via collaterals, (IRc), and “Wound-Targeted Revascularization” (WTR) within the broader perspective of “Intentional Topographic Revascularization” (ITR) in patients with CLTI foot. ITR affords a novel conceptualization of regional foot reperfusion via deliberate anatomical and functional orientation of the foot arterial flow to the ischemic zones (owing specific pedal arteries and regional collaterals). The analysis of data revealed significant differences in the current clinical definitions, interpretation, and application methods of TR. Inconsistent views on DR were also observed in the context of “wound-dependent” localization and the identification of the most suitable target foot artery for treatment. Unfortunately, a standardized definition of angiosome-oriented DR, IR, IRc, and WTR has not been established. Owing to the lack of a universally accepted definition and unified anatomical and functional foot arterial occlusive disease stratification, evidence supporting the applicability of ITR (by all its variants) is still awaited.