Pedal Arch Research Articles

Pedal Acceleration Time (PAT): A Novel Predictor of Limb Salvage

In the setting of Peripheral Arterial Disease (PAD), pedal arch interrogation by ultrasound has not been well described. Patients with noncompressible vessels and/or open wounds of the foot may preclude the use of ankle-brachial indices, toe pressure measurements, or TcPO2, respectively. We propose that pedal artery interrogations with Pedal Acceleration Time (PAT) can be a predictor for limb salvage in patients with Chronic Limb-Threatening Ischemia (CLTI). A retrospective review of a prospectively kept database was performed from 2018 to 2019. Patients with pending amputation due to severe infection (WIFI infection class 2 and 3) were excluded from the study. We identified 73 limbs with CLTI that fit the inclusion criteria. Data included WIFI classification, age, gender, cardiovascular risk factors, PAT, ABI, and TBI when reliable, were collected. PAT measurements were categorized into 4 classifications; 1 (40-120 msec), 2 (121-180 msec), 3 (181-224 msec), and 4 (Greater than 225 msec). Statistical analyses were performed. Seventy-three limbs with CLTI were included in our study. All patients underwent arterial revascularization with either percutaneous technique or arterial bypass. Limb salvage was achieved in 59 (81%) of the 73 limbs. All 59 limbs had a 2-classification improvement in their PAT following interventions. A total of 14 (19%) limbs without improvement in their PAT underwent above ankle level amputations. An improvement in PAT classes to class 1 or 2 is associated with limb salvage. Patients with noncompressible ankle pressures or nonobtainable toe pressures poses a challenge in the complete assessment of WIFI classification. Our group has shown that PAT can be used in the scoring system for severity of ischemia in conjunction with current WIFI classification. Our data suggests that limb salvage correlates with post procedure PAT in category 1 and 2. Therefore we propose that PAT be added as part of the WIFI classification.

Systematic review of inframalleolar endovascular interventions and rates of limb salvage, wound healing, restenosis, rest pain, reintervention and complications.

ObjectivesPeripheral artery disease is estimated to affect 237 million individuals worldwide. Critical limb ischaemia, also known as chronic limb threatening ischaemia is a consequence of the progression of peripheral artery disease which occurs in ∼21% of patients over a five-year period. The aim of this systematic review is to assess the use of additional below-the-ankle angioplasty in comparison to the use of above-the-ankle angioplasty alone, and the subsequent rates of amputation, wound healing, restenosis, rest pain, reintervention and complications.MethodsThis systematic review was undertaken in accordance with PRISMA guidelines following a registered protocol (CRD42019154893). Online databases were searched using a search strategy of 20 keywords. Included articles reported the outcome for inframalleolar (pedal artery, pedal arch, plantar arteries) angioplasty with additional proximal angioplasty in comparison to proximal angioplasty alone. GRADE assessment was applied to assess the quality of the evidence.ResultsAfter screening 1089 articles, 10 articles met the inclusion criteria. Comparative performance assessment of below-the-ankle with above-the-ankle versus above-the-ankle angioplasty alone was undertaken in 3 articles, with the remaining 7 articles reporting outcomes of below-the-ankle with above-the-ankle angioplasty with no distinct comparator group. Significant decrease in major lower limb amputation at the last follow-up in the below-the-ankle group when compared with the above-the-ankle angioplasty alone group was observed in a single study (3.45% vs. 14.9%, p < 0.05). Improved wound healing rate at follow-up in the below-the-ankle group versus above-the-ankle angioplasty alone group was also reported in a single study (59.3% vs. 38.1%, p < 0.05). Subsequent rate of amputation after below-the-ankle angioplasty has been estimated as 23.5%.ConclusionTo date, there is a lack of studies assessing inframalleolar interventions and their use in improving limb salvage, wound healing and symptomatology. Prospective RCTs should be undertaken with adequate participant numbers to be sufficiently powered and report clinically important end-points.

Comparison of Pedal Arch Anatomy in First and Second Grade Elementary School Students in Denpasar with Flat Foot and Normal Foot

Flat foot is a condition which pedal arch is absent. This condition is count physiological if found in infants and children at a certain age due to incomplete development of bone structure and surrounding tissue. Flat foot is a common condition in pediatrics, which affects about 20% to 30% of the world's population. The prevalence of flat foot will decrease concomitantly with age. At two years old, 94% of children experience flat foot and only 4% at ten years old experience this condition. Most children will show complete and normal development of the sole foot at 12 years old. Pedal arch is one of the important parts that affect the anatomical structure of the lower limb and foot biomechanical. This study aims to compare the anatomical structure of the pedal arch in patients with flat foot and normal foot from Arch Height Index (AHI), Plantar Arch Index, Calcaneal Pitch Angle (CP), Talo-Horizontal Angle (TH), and Meary’s talus-first metatarsal (T-1MT). This study is an analytical study with a cross sectional approach using a sample of 30 elementary school students in Denpasar. The data obtained were analyzed using descriptive analysis and comparative test. In this study, we found significant differences in the plantar arch index and calcaneal pitch angle between students with normal foot and flat foot. We also found no significant differences in AHI, T-1MT and TH between students with normal foot and flat foot.

What is the impact of infrapopliteal endovascular intervention on free flap survival in diabetic foot reconstruction?

BackgroundThe combination of endovascular intervention and microvascular free flap transfer has been effectively used for chronic ischemic wounds of lower limb. The aim of this study was to determine the influence of angioplasty on free flap survival in diabetic foot ulcer reconstruction.MethodsA retrospective research was conducted for 46 diabetic patients with chronic ulcer of the foot. All patients underwent free flap reconstruction because of their non-healing wound with tendon or bone exposure. Patient’s demography, clinical data related to vascular status, vascular intervention, and free flap transfer procedure were collected. Flap survival rate was compared between the group with severe arterial stenosis group and non-severe stenosis group. It was also compared among groups with different revascularization results.ResultsThe average age of patients was 56.2 ± 10.8 years. There were 14 (30.4%) men and 32 (69.6%) women. Of 46 patients, 23 (50%) had severe infrapopliteal arterial stenosis. All 23 patients underwent endovascular intervention. Their final results of the pedal arch were type 1 in 13 patients, type 2A in 7 patients, type 2B in 2 patients, and type 3 in 1 patient. Total flap necrosis was found in 5 (10.9%) cases, marginal necrosis in 4 (8.7%) cases, and wound dehiscence in 4 (8.7%) cases. There was no significant difference in flap loss between severe arterial stenosis patients and non-severe arterial stenosis patients. In the severe arterial stenosis group, after endovascular intervention, patients with type 1 of pedal arch had a significantly lower rate of total flap necrosis than others. There was no association between the use of revascularized recipient artery and flap survival.ConclusionsOur study revealed that the quality of pedal arch was crucial for free flap survival. Thus, PTA should aim to re-establish a complete pedal arch to increase wound healing rate and flap success.

Influence of time interval between endovascular intervention and free flap transfer on flap outcomes in critical limb-threatening ischemia: A retrospective analysis of 64 consecutive cases

Arterial revascularization and free flap reconstruction is safe and effective for limb salvage in patients with critical limb-threatening ischemia (CLTI). This study aimed to determine whether reconstruction outcomes were affected by the time interval between endovascular treatment and free flap transfer in lower extremity reconstruction for critical limb ischemia. Patients who underwent endovascular intervention and subsequent free flap reconstruction with >6 months of follow-up were reviewed. Those with wounds with oncological and traumatic etiologies were excluded. Patients' demographics, risk factors, details of microsurgical procedures, details of endovascular intervention, and flap outcomes were collected. Overall, 64 consecutive patients (M:F = 50:14 and mean age, 57.3 [range, 29-82] years) were evaluated between November 2011 and October 2019. Angioplasty failed in three patients. For soft-tissue reconstruction, anterolateral free flaps were used most frequently (n = 54 and 84.4%). Flap-related complications developed in 12 cases, of which five cases included total flap necrosis. The interval between endovascular intervention and free flap transfer was not associated with flap loss in multivariate regression analysis. Patients with kidney transplants and higher serum creatinine were associated with total flap necrosis. Advanced age, failed angioplasty, and perfusion status of the pedal arch were associated with major flap complications. The time interval between endovascular treatment and free flap reconstruction was not associated with flap complications. Free flap reconstruction of chronic wounds caused by CLTI can be safely planned regardless of the time duration from preoperative angioplasty.

GLASS (Global Limb Anatomic Staging System): a critical appraisal.

THE Global Vascular Guidelines (GVGs) propose a new Global Anatomic Staging System (GLASS) resulting in three stages of complexity for intervention. The aim of this study was to retrospectively classify a large cohort of CLTI patients according to the GLASS, evaluating its distribution in a real-world setting. Retrospective, single center, observational study enrolling all consecutive CLTI patients submitted to infra-inguinal endovascular revascularization in our institution, between June 2014 and September 2019. Patients were categorized according to the GLASS for femoro-popliteal (FP), infra-popliteal (IP) and infra-malleolar grading. FP and IP grades were merged to get the final GLASS stage for each limb. The study included 1995 CLTI patients who underwent 2850 endovascular procedures in which 6009 arterial lesions were successfully treated. The FP segment was classified as: 1292 (45.3%) grade 0, 475 (16.6%) grade 1, 159 (5.6%) grade 2, 209 (7.4%) grade 3, and 715 (25.1%) grade 4. The IP segment was classified as: 1529 (53.6%) grade 0, 183 (6.4%) grade 1, 80 (2.8%) grade 2, 207 (7.3%) grade 3, and 851 (29.9%) grade 4. The combination of FP and IP grading led to GLASS stages: 922 (32.3%) stage 1, 375 (13.2%) stage 2, 1472 (51.6%) stage 3. The distribution of the FP, IP and final GLASS grading was mainly grouped at the two extremes, letting the intermediate grades rather scarce. The majority of patients present with an absent or severely diseased pedal arch, stressing the need to incorporate infra-malleolar disease into the GLASS.

Comparison of endovascular infrapopliteal revascularization strategies based on the angiosome model in diabetic patients within critical limb ischemia

Abstract Background The relevance of an angiosome model for infrapopliteal endovascular interventions (EVT) in diabetic patients is still in debate because the lesions are more likely to be diffuse with a different pattern of collateral arteries ranging from reduced to normal caliber. The aim of this study was to analyse the outcome of two different endovascular infrapopliteal interventional strategies (Group I: angiosome-based direct revascularization -DR- vs. Group II: complete (direct + indirect) revascularization strategy -CR-) in diabetic patients with critical limb ischemia. Furthermore we analyzed the outcome if DR or CR failed and only indirect revascularization (IR) or no revascularization was possible. Both groups were differentiated in patients with collaterals, defined as an intact pedal arch (immediate or after pedal PTA). Patients and methods We performed a prospective cohort study in routine angiologic patients. The database includes 91 consecutive EVT with two intrapopliteal interventional strategies performed in 68 diabetic patients (pts.; 24 female, 44 male, mean age 73±10 years) between 2013–2015 and 2016–2019. The study included only patients with CLI (Rutherford class 4 or greater) with a critical subtotal stenosis or occlusion of at least one artery below the knee. EVT were performed mainly by an antegrade approach and with the use of 5F sheaths. In case of failure to recanalise, a retrograde approach was attempted. Positive clinical outcome was defined as wound healing without amputation or wound healing after minor amputation, combined with a symptom improvement to Rutherford category 0 or 1 after 6 months. The clinical outcome proportions were compared using the Fisher's exact test. Results An angiosome-based direct reperfusion (DR) of the artery supplying the ischemic tissue and a complete (both direct and indirect, CR) revascularization strategy demonstrated a similar positive clinical outcome (92,6% vs. 90,5%; p=0.594). Indirect revascularization showed a significantly lower positive outcome in comparison to a successful DR as well as CR strategy (33,3% vs 92,6%, p=0.0003; 40% vs 90,5%, p=0.001). IR outcome improved by the presence of collaterals (66,7% vs. 30,8%). Conclusions In case of successful intervention, both strategies (DR and CR) yielded a similarly high proportion of positive clinical outcome. The role of collaterals and the pedal arch are important for the clinical outcome in patients in whom only indirect revascularization was possible, because of unsuccessful CR or DR. The time of the procedure/radiation, the risk to reopen more than one vessel, the necessary amount of contrast medium and final the costs of the procedure should also be considered for an individually based decision process to perform an angiosome-based direct or a complete revascularization. Funding Acknowledgement Type of funding source: None

Isolated Metatarsal Artery Balloon Angioplasty for Toe Salvage in Critical Limb Ischemia: A Case Report

Purpose: To report a case of percutaneous balloon angioplasty (PTA) performed in the second metatarsal artery for treatment of a non-healing forefoot wound without proximal intervention. Methods and Results: An 80-year-old diabetic woman with a 1.5-year history of a non-healing right second digit ulcer refractory to conservative management underwent a lower extremity arteriogram. Angiography demonstrated unobstructed flow from the aortic bifurcation through to the pedal arch, with an isolated occluded segment in the second metatarsal artery wound supply. This was treated with 1.5 mm balloon angioplasty, with completion angiography demonstrating restored flow to the wound base. There were no procedural events and the wound completely healed after 9 months. Conclusion: Isolated angioplasty of the arteries distal to the pedal arch may be technically feasible and clinically valuable in selected cases.

Infrapopliteal Anatomic Severity and Delayed Wound Healing in Patients With Chronic Limb-Threatening Ischemia in the Era of the Global Limb Anatomic Staging System

Purpose: To investigate the prognostic impact of infrapopliteal (IP) artery anatomic severity according to the Global Limb Anatomic Staging System (GLASS) on delayed wound healing in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: This study retrospectively analyzed 639 limbs with tissue loss in 484 CLTI patients (mean age 74±10 years; 300 men) presenting IP lesions treated with endovascular therapy between April 2010 and December 2015. Two-thirds of patients had diabetes (323, 67%) and over half were on hemodialysis (255, 53%). More than a third of the limbs (251, 39%) were classified as clinical stage 4 according to the Wound, Ischemia, and foot Infection (WIfI) system. IP anatomic severity was classified based on preprocedural angiography according to the GLASS. Severity of arterial calcification was assessed using high-intensity fluoroscopy and classified into 3 groups: none (grade 0), unilateral (grade 1), and bilateral (grade 2). Poor below-the-ankle (BTA) runoff was defined as the lack of a pedal arch with 0 to 1-vessel runoff within the dorsal pedis artery and the lateral and medial plantar arteries. The outcome measure was 1-year wound healing. The association of anatomic characteristics with delayed wound healing was evaluated using Cox proportional hazards regression analysis. Outcomes are presented as the adjusted hazard ratio (HR) with 95% confidence interval (CI). Results: During a mean follow-up of 22±19 months, the 1-year cumulative wound healing rate was estimated to be 59.0% (95% CI 54.5% to 63.5%). Multivariable analysis demonstrated independent associations between delayed wound healing and IP calcification grade (HR 1.24, 95% CI 1.02 to 1.50, p=0.027) and poor BTA runoff (HR 1.39, 95% CI 1.04 to 1.85, p=0.025) but not the GLASS IP grade (HR 0.92, 95% CI 0.82 to 1.14, p=0.21). Conclusion: The current study revealed that IP arterial calcification and poor BTA runoff were significantly associated with delayed wound healing, whereas the GLASS was not predictive of wound healing.

Duplex Ultrasound Defined Angiosome With the Use of Pedal Acceleration Time as a Predictor to Wound Healing

We have established that pedal acceleration time (PAT) in nondiabetic limbs are highly correlative with ankle-brachial indices. We propose that PAT can be utilized in diabetic patients with noncompressible vessels and is an excellent predictor of wound healing. We performed a retrospective analysis in a prospective data base of diabetic patients with chronic limb-threatening ischemia (CLTI). We focused on patients with diabetes and isolated infrapopliteal arterial occlusive disease. Fifty-four limbs with WIFI score and documented CLTI who underwent angiographic interventions were analyzed. A complete pedal arch duplex was performed, PAT (milliseconds) was measured in the arcuate artery, dorsal metatarsal artery, medial, lateral, and deep plantar arteries. These measurements correspond to the angiosome of tissue loss which were obtained before and after interventions. A Fisher's exact test was used for data analysis. Based on previous report, PAT was categorized into four classes (Table). All CLTI patients were in class 4, which is defined as a PAT of greater than 225 ms. Of the 54 diabetic limbs, 44 achieved wound healing and 10 required higher level amputation. Patients with wounds prior to intervention had a mean PAT 237.6 + ms in the targeted artery of the foot. Complete wound healing was associated with a mean PAT of 114.2+ ms in the target angiosomic artery of the foot, regardless of direct or in-direct revascularization of the tibial arteries (P < .001). Limb loss was associated with a mean PAT of 278.4+ ms (P < .001) following intervention. Our group established that PAT demonstrates a high correlation with ABI in patients with compressible arteries. Based on current data, PAT is also a reliable noninvasive examination for patients with CLTI. This novel use of duplex-specific angiosome in the area of foot wounds demonstrate high predictability of wound healing. We conclude that duplex imaging of the pedal vessels, using PAT in particular, should be performed in all CLTI patients to aid in treatment of these complex patients.TablePedal acceleration time (PAT) classificationNo ischemia class 1Mild ischemia class 2Moderate ischemia class 3Severe ischemia class 4Clinical SymptomsAsymptomatic>2 blocks claudication>2 blocks claudicationCritical Limb Ischemia (Tissue loss, rest pain)PAT20-120 ms121-180 ms181-224 msGreater than 225 msABI1.3-0.900.89-0.690.68-0.500.49-0.00 Open table in a new tab

Competing Risk Analysis of the Impact of Pedal Arch Status and Angiosome-Targeted Revascularization in Chronic Limb-Threatening Ischemia

In the context of chronic limb-threatening ischemia, the prognostic impact of angiosome-targeted revascularization and of the status of the pedal arch are debated. This series includes 580 patients who underwent endovascular (n=407) and surgical revascularization (n=173) of the infrapopliteal arteries for chronic limb-threatening ischemia associated with foot ulcer or gangrene. The risk of major amputation after infrapopliteal revascularization was assessed by a competing risk approach. A subanalysis was made separately for patients who underwent endovascular or open surgical revascularization. At 2years, survival was 65.1% and leg salvage was 76.1%. Multivariable competing risk analysis showed that C-reactive protein ≥10mg/dL, diabetes, rheumatoid arthritis, increased number of affected angiosomes, and the incomplete or total absence of pedal arch compared with complete pedal arch (CPA) were independent predictors of major amputation after infrapopliteal revascularization. Multivariable analysis showed increasing risk estimates of major amputation in patients with incomplete (subdistribution hazard ratio [SHR], 2.131; 95% confidence interval [95% CI], 1.282-3.543) and no visualized pedal arch (SHR, 3.022; 95% CI, 1.553-5.883) compared with CPA. Pedal arch was important even if angiosome-targeted revascularization was achieved: Angiosome-directed revascularization in presence of CPA had a lower risk of major amputation (adjusted SHR, 0.463; 95% CI, 0.240-0.894) compared with angiosome-directed revascularization without CPA. In the subanalysis, among patients who underwent endovascular revascularization, CPA (SHR, 0.509; 95% CI, 0.286-0.905) and angiosome-targeted revascularization (SHR, 0.613; 95% CI, 0.394-0.956) were associated with a lower risk of major amputation. Competing risk analysis showed that a patent pedal arch had significant impact on leg salvage and that the subset of patients undergoing endovascular procedure may most benefit of an angiosome-targeted revascularization.

4:03 PM Abstract No. 49 Outcomes of below-the-ankle revascularization and impact of pedal arch patency in critical limb ischemia

Report outcomes of below-the-ankle (BTA) revascularization in critical limb ischemia (CLI) and investigate the association of pedal arch patency with limb salvage. A single-center review was conducted of CLI patients undergoing BTA revascularization (2009-2018). Records were reviewed for demographics, comorbidities, technical details and wound healing. Postintervention arteriograms were classified as demonstrating a complete (CPA), incomplete (IPA) or absent (APA) pedal arch. Clinical endpoints included overall survival (OS), minor (ankle preserving) amputation-free survival (AFS) and major (above-the-ankle) AFS at 6- and 12-months following initial BTA intervention. Sixty consecutive Rutherford Class 5 and 6 patients underwent BTA revascularization with concurrent tibial (100%) and femoropopliteal (55%) endovascular therapy. The mean age was 69 years with 58% male, 82% diabetic, 56% CKD and 48% smoker. Angioplasty of 81 BTA lesions (53 dorsalis pedis, 16 pedal arch, 12 lateral plantar) was performed including adjunctive orbital atherectomy in 3 cases. The pedal loop technique was used in 6 cases and retrograde pedal access technique in 18 cases. The 6- and 12-month OS was 95% and 95% with 3 mortalities attributed to cardiac arrest on postop day 32, 44 and 59. The 6- and 12-month minor AFS rate was 63% and 63%, respectively, with average amputation at 0.9 months. The 6- and 12-month major AFS rate was 65% and 58%, respectively, with average amputation at 2.5 months. Mean follow-up was 18.3 months with 43% achieving complete wound healing on average at 7.4 months and 42% censored due to major amputation or death. Postintervention, there were 25 (42%) complete pedal arches (CPA) and 35 (58%) incomplete pedal arches. Subgroup analyses showed no significant difference (P > 0.05) between pedal arch status and demographics, comorbidities, OS, major AFS or wound healing rates. However, the association between CPA and minor AFS was significant (P < 0.001). This study establishes a CPA as predictive of avoiding minor amputation in patients with CLI. Further study to stratify angiographic endpoints and patient selection for BTA intervention is needed.

Impact of pedal arch revascularization on clinical outcomes of diabetic patients with critical limb ischemia

Aim The aim was to evaluate the effect of pedal arch revascularization in diabetic patients suffering from critical limb ischemia (CLI) on wound healing, time to heal, and limb salvage. Materials and methods The study was carried out from March 2016 to February 2019 at Sohag University Hospitals on 60 diabetic patients diagnosed with CLI. Pedal arch revascularization was combined with traditional management. Patients were divided into complete pedal arch (CPA), incomplete pedal arch (IPA), and absent pedal arch (APA) groups. Wound healing, time to heal, limb salvage, and freedom from minor amputations were evaluated and compared among the patient groups. Results The patients were classified into CPA group (15 patients, 25%), IPA (26 patients, 43.3%), and APA group (19 patients, 31.7%). There were no statistical difference between groups in age, sex, or risk factors. CPA patients showed a significantly higher rate of wound healing and shorter time-to-heal than other patient groups, 93.3% in CPA, 73.1% in IPA, and 52.6% in the APA group (P=0.003). Time to heal was 3.4±2.5 months in CPA patients, 4.0±2.9 in IPA, and 6.1±3.2 in APA group (P=0.02). Limb salvage rate was significantly better in CPA patients (100% in CPA, 88.5% in IPA, and 68.4% in APA group; P=0.01). Freedom from minor amputation was 86.6, 76.9, and 47.4% (P=0.086) in CPA, IPA, and APA group, respectively. Conclusion Pedal arch patency has a positive clinical impact on wound healing rate, time to heal, and limb salvage in the management of diabetic patients with CLI undergoing endovascular intervention.

Impact of Endovascular Pedal Artery Revascularisation on Wound Healing in Patients With Critical Limb Ischaemia

Objective The present study investigated the impact of endovascular pedal artery revascularisation (PAR) on the clinical outcomes of patients with critical limb ischaemia (CLI). Methods This retrospective analysis of a single centre cohort included 239 patients who underwent endovascular revascularisation of infrapopliteal arteries for a chronic ischaemic wound. PAR was attempted in 141 patients during the procedure. After propensity score matching, there were 87 pairs of patients with and without PAR. Results After the matching, the two groups showed balanced baseline clinical and lesion characteristics. PAR was achieved in 60.9% of the PAR group. Direct angiosome flow was more frequently obtained in the PAR group than in the non-PAR group (81.6% vs. 34.5%; p 3 mg/dL (HR 0.591, 95% CI 0.386–0.904; p = .015), and pre-procedural absence of pedal arch (HR 0.628, 95% CI 0.431–0.916; p = .016) were associated with impaired wound healing. Conclusion Successful PAR significantly improved wound healing in patients with CLI. Thus, efforts should be made to revascularise the pedal arteries, especially when the pedal arch is completely absent.

Pedal Arch Patency Guarantees Wound Healing and Limb Salvage of Transmetatarsal Amputation Following Limb Revascularization

Introduction - Transmetatarsal amputation(TMA) is necessary whenever several toes or the forefoot are affected by gangrene due to peripheral arterial disease (PAD). Revascularization before TMA is mandatory to guarantee wound healing. Currently, factors that may affect TMA healing are not well investigated. The study's aim was to evaluate the role of foot arteries in TMA healing and limb salvage after revascularization. Methods - All patients treated for PAD with chronic limb threatening ischemia(CLTI) between April-2012 and November-2017 were collected in a prospective database. Retrospective analysis was performed including only patients who underwent TMA after any type of revascularization (surgical, endovascular). Patient's demographics and clinical characteristics were assessed. Pre-operative digital subtraction angiography(DSA) were reviewed together with interventional data to determine the patency of foot arteries and the presence of in-line flow to the foot. The pedal arch patency was classified1 as: no pedal arch(NPA), incomplete pedal arch(IPA) and complete pedal arch(CPA). Clinical and Duplex follow-up was performed at 3,6 and every 6 month thereafter. The study's primary endpoints were: wound healing (WH), Limb Salvage(LS) and impact of foot arteries and pedal arch patency on LS and WH on the basis of Chi square test and Log-Rank test in the Kaplan-Meier analysis. Secondary endpoints were: primary(PP), assisted(AP) and secondary patency(SP) and patient survival(S). Results - A total of 112 limbs in 105 patients (median age 72 ±10 years, male 76.2%, 7 patients treated bilaterally) satisfying the inclusion criteria were treated in the study period. Complete data on the foot arteries were available in 104(93%) limbs. Coronary artery disease, diabetes mellitus, kidney disease and chronic obstructive pulmonary disease(COPD) were present in 39.6%, 67.6%, 52%(dialysis 28.1%) and 38.4%, respectively. Clinical presentation was Rutherford stages 5 and 6 in 10.7% and 89.3%, with 69.7% of wounds presenting infection. Surgical and endovascular revascularization were performed in 37.5% and 62.5% of cases with a technical success of 87.5%. Dorsalis pedis and common plantar arteries patency, NPA, IPA and CPA were found in 55.8%, 54.8%, 21.2%, 60.6% and 18.3%, respectively. Direct in-line flow to the foot arteries was achieved in 72.1% of cases. The mean follow-up was 17.7 months. WH was 57.1%, 89.3% and 98.2% at 6,12 and 24-month, respectively. LS was 81.1%, 79.5% and 77.5% at 6,12 and 24-month, respectively. The study's secondary endpoints are reported in table 1. TMA healing and limb salvage were not affected by patency of either dorsalis pedis artery or plantar artery (P=0.26 and P=0.33, respectively). Similarly, direct in-line flow was not associated with better wound healing and limb salvage rates (P=0.12 and P=0.35, respectively). In contrast, the presence of CPA compared to IPA or NPA was associated with higher wound healing (at 12-month: 93.3% vs 83.3%. P=0.01) and limb salvage rates (at 12-month: 100% vs 75%. P=0.019).Table 1secondary endpoints at 6,12 and 24-monthPP (%)AP (%)SP (%)S (%)6-month68.471.177.869.112-month57.362.571.86424-month50.855.668.452.1 Open table in a new tab Conclusion - The study results suggest that the pedal arch patency has a principal role in wound healing and limb salvage after transmetatarsal amputation in patients with CLTI undergoing limb revascularization.

Hybrid Treatment for Ischemic Limb Salvage in Patients with Subacute Complex Infrainguinal Arterial Occlusions

To evaluate safety and efficacy of a hybrid technique using a Fogarty catheter and an angioplasty balloon to retrieve organized thrombosis then endovascular therapy for underlying chronic lesions in subacute ischemic limbs with complex long infrainguinal arterial occlusions. Retrospective study. Patients presented with Rutherford (4:6) critical limb threatening ischemia (CLTI) and reported acute pain onset or worsening of existing symptoms and presented between 15 days and 3 months duration. Included cases underwent hybrid management for limb salvage performing short time inflation with angioplasty balloon to disrupt fibrosis then passing a Fogarty catheter to retrieve thrombosis and finally treating the underlying arterial lesions. Patient characteristics and comorbidities were reported; degree of disease in the crural vessels was described using the Society of Vascular Surgery modified runoff score. Pedal runoff was assessed according to pedal arch state. Study outcomes included technical success, 1-year patency, limb salvage, and amputation free survival (AFS) rates. Fifty-four patients (mean age 57.2), with a mean symptom duration of 7.3 ± 2.6 weeks, underwent the described hybrid management protocol. Mean runoff score was 7.5 ± 1.3. Distal embolization was reported in 11 (20.4%) cases. Technical success was 90.7%. Primary, assisted primary, and secondary patency rates were 64.8%, 75.9%, and 79.6%, respectively. The 1-year AFS was 77.8%. Limb salvage rate was 88.9%. This study suggests that reported hybrid revascularization modality is considered a safe and effective alternative for treating subacute ischemic limb patients.

Editor's Choice – Impact of Endovascular Pedal Artery Revascularisation on Wound Healing in Patients With Critical Limb Ischaemia

The present study investigated the impact of endovascular pedal artery revascularisation (PAR) on the clinical outcomes of patients with critical limb ischaemia (CLI). This retrospective analysis of a single centre cohort included 239 patients who underwent endovascular revascularisation of infrapopliteal arteries for a chronic ischaemic wound. PAR was attempted in 141 patients during the procedure. After propensity score matching, there were 87 pairs of patients with and without PAR. After the matching, the two groups showed balanced baseline clinical and lesion characteristics. PAR was achieved in 60.9% of the PAR group. Direct angiosome flow was more frequently obtained in the PAR group than in the non-PAR group (81.6% vs. 34.5%; p<.001). Subintimal angioplasty (47.1% vs. 29.9%; p=.019) and pedal-plantar loop technique (18.4% vs. 0%; p<.001) were more frequent in the PAR group. At the one year follow up, the PAR group showed greater freedom from major amputation (96.3% vs. 84.2%; p=.009). The wound healing rate, overall survival, major adverse limb event, and freedom from re-intervention did not differ significantly between the two groups. However, the patient subgroup with successful PAR showed a higher wound healing rate than the non-PAR group (76.0% vs. 67.0%; p=.031). In a multivariable Cox proportional hazards regression model, successful PAR (hazard ratio [HR] 1.564, 95% confidence interval [CI] 1.068-2.290; p=.022) was identified as an independent factor associated with improved wound healing, whereas gangrene (HR 0.659, 95% confidence interval [CI] 0.471-0.923; p=.015), C reactive protein >3mg/dL (HR 0.591, 95% CI 0.386-0.904; p=.015), and pre-procedural absence of pedal arch (HR 0.628, 95% CI 0.431-0.916; p=.016) were associated with impaired wound healing. Successful PAR significantly improved wound healing in patients with CLI. Thus, efforts should be made to revascularise the pedal arteries, especially when the pedal arch is completely absent.

Pedal Arch Patency Is Superior in Predicting Limb Salvage for Infrapopliteal Endovascular Intervention to Tibial Vessel Complexity, WIfI Score, or Global Limb Anatomic Staging System Grade

Pedal Arch Patency Is Superior in Predicting Limb Salvage for Infrapopliteal Endovascular Intervention to Tibial Vessel Complexity, WIfI Score, or Global Limb Anatomic Staging System Grade

IF02. Angiographic Patterns at the Ankle and Foot Level in Patients With Critical Limb-Threatening Ischemia Correlate With Healing of Transmetatarsal Amputation

Patients with critical limb-threatening ischemia with chronic forefoot wounds often need transmetatarsal amputation (TMA). Lower extremity revascularization improves healing and prevents major amputation. Additionally, the condition of the pedal arch plays an important role in the healing process and is, therefore, possibly associated with major amputation conversion. The aim of this study was to investigate the relation between TMA healing and distal angiographic arterial patterns using two anatomic classification systems. Cases were selected from a single-center retrospective review conducted among patients who had all of the following: TMA, endovascular revascularization intervention, and available angiographic imaging of the leg including the ankle and foot. All patients were included from the University of California San Francisco Medical Center from January 1, 2008, to December 31, 2016. A total of 38 cases with TMA, endovascular revascularization intervention and available imaging was obtained. All angiographic images were scored using two anatomic classifications—the Pedal Outflow Modifier of the Global Anatomic Staging System and the Pedal Arch Classification developed by Kawarada et al (Table I). Scoring was done separately by two observers who reached consensus on all scores. The primary end point was TMA healing after 6 months. A clear trend was seen when it comes to TMA healing in relation to both the Pedal Outflow Modifier and Pedal Arch Classification (Table II). However, owing to the small number of cases there was no statistical significance (P = .078). There seems to be a clear trend in the correlation between the condition of the pedal arch and wound healing after TMA. To achieve statistical significance, additional cases as well as bypass surgery will be added. Anatomic classification of the pedal arch in the future may become an adjunct to the clinical decision making process on determining amputation level.Table IPedal outflow modifier and pedal arch classificationMeasureDescriptionPedal outflow modifier P0Target artery crosses ankle into foot, with intact pedal arch P1Target artery crosses ankle into foot; absent or severely diseased pedal arch P2No target artery crossing ankle into footPedal arch classification Type 1Both dorsalis pedis and plantar artery patent Type 2AOnly dorsalis pedis patent Type 2BOnly plantar artery patent Type 3Both dorsalis pedis and plantar artery not patent Open table in a new tab Table IITransmetatarsal amputation (TMA) healing rates by anatomic class after 6 monthsTMA healedPedal outflow modifier P02/3 (67%) P15/26 (19%) P21/9 (11%)Pedal arch classification Type 12/3 (67%) Type 2A4/15 (27%) Type 2B1/8 (13%) Type 31/12 (8%) Open table in a new tab

PC106. Pedal Acceleration Time: A Novel Predictor of Limb Salvage

In the setting of peripheral artery disease, pedal arch interrogation by ultrasound is a relatively novel technique. Patients with noncompressible vessels preclude the use of ankle-brachial indices or toe pressure measurements. Our group devised a technique for measuring pedal artery flow by measuring the pedal acceleration time (PAT) in the pedal arch. We proposed that this new method has utility in determining limb salvage comparable to current classification using the Wound, Ischemia, and foot Infection (WIfI) scoring system. We performed a retrospective review of a prospectively kept database of 70 patients in an 18-month period. Data included WIfI classification, age, sex, cardiovascular risk factors, PAT, and ankle-brachial index when reliable. PAT was calculated. The PAT measurement was classified into four categories: category 1, 40-120 milliseconds; category 2, 121 to 180 milliseconds; category 3, 181 to 224 milliseconds; and category 4, >225 milliseconds. Statistical analyses were performed using linear regression and analysis of variance testing. The primary outcome measure was limb salvage. Limb loss was defined by amputation higher than the ankle. Interventions included surgical bypass and catheter-based interventions. Seventy patients with critical limb ischemia were included in our study. Two patients underwent revascularization of both limbs for a total of 72 limbs studied. All patients underwent arterial revascularization with either percutaneous technique or arterial bypass. Limb salvage was achieved in 44 (60%) of the 72 limbs. All 44 limbs had a two-category improvement in PAT. Twenty-nine (40%) limbs underwent a higher level amputation. Of the 29 amputations, 21 patients had WIfI infection score of 2 or 3 with a postprocedure PAT category of 1 or 2. Eight patients had no infection; however, the PAT after the procedure was category 3 or 4. It is well known that patients with noncompressible ankle pressures or nonobtainable transcutaneous oxygen pressure and toe pressures cannot always provide accurate information. Our group proposes that PAT be used in the scoring system for severity of ischemia in place of the current methods when they are unreliable. Our data suggest that limb salvage correlates with postprocedure PAT in categories 1 and 2. In our population of patients, 21 limbs had an infection score of 2 or 3 (as defined by WIfI scoring), which clearly had a negative impact on limb preservation despite significant improvement in arterial perfusion. As such, a P value of <.0001 and improvement of two PAT categories may be predictive of limb salvage.