Comparison between direct and indirect revascularization of below-the-knee arterial occlusive diseases based on foot angiosome concept

Abstract

Objective Ischemic wounds of the foot are the most common cause for major amputations in vascular surgical patients. It can be presumed that revascularization of the artery directly supplying the ischemic angiosome may be superior to indirect revascularization (IR) of the concerned ischemic angiosome. Patients and methods This prospective study enrolled patients with critical limb ischemia due to isolated infrapopliteal disease (stenosis of ≥70% or complete total occlusions of the crural arteries) presented to our Vascular Department between April 2017 and April 2018. We categorized the treatment groups into two main groups: direct revascularization (DR) and IR. We excluded patients with acute limb ischemia, inflow lesions above the knee, sepsis, myocardial infarction during the previous 14 days, blue toe syndrome (microembolization), and patients who cannot ambulate. Results In this study, there were 23 patients with forefoot ischemia, eight patients had ischemic heel, and two patients had mid-foot ischemia. All patients were followed at 1, 6, and 12 months postoperatively for wound healing, major amputation, or death. Wound healing at 1, 6, and 12 months for DR versus IR was 16.6 versus 9.09%, 56.3 versus 33.3%, and 93.75 versus 87.75%, respectively. The limb salvage rate in the DR group was 88.9% and in IR group was 72.7%. The mortality was 10% for DR and 15.4% for IR at 12 months. Conclusion To obtain better wound healing rates, DR of the ischemic angiosome should be considered whenever possible. Revascularization should not be denied to patients with indirect perfusion of the ischemic angiosome, as acceptable rates of limb salvage are obtained.