Critical Limb Ischemia

Background
To evaluate the eventual clinical benefit of wound targeted revascularization (WTR) guided by the angiosomes concept (AC) in ulcer healing, limb preservation, and survival for primary below-the-knee angioplasties , in a seven-year prospective homogeneous registry of diabetic neuro-ischemic, Rutherford 5, Wagner 2-4 foot ulcers.

Methods
From April 2009 to November 2016, a series of 188 limb-threatening neuro-ischemic foot wounds in 160 diabetic patients (70% men), mean age 71.9 years were prospectively recorded and scheduled for infragenicular endovascular treatment. Improved wound healing was the primary endpoint for treatment. Wound targeted revascularization (WTR) by primary endovascular approach following the AC direct branches and/or appended collateral network was attempted in each presentation. In cases in which first WTR direct approach (Group A /n=113 limbs) proved technically unachievable, either alternative WTR via collaterals (WTRc, or Group B /n=28 limbs), or compulsory wound indifferent revascularization (WIR, or Group C /n=35 limbs) for limb salvage were undertaken.

Results
The global wound-targeted revascularization technical achievement (Groups A and B) following the AC (with or without mediation by regional collaterals) was 75%. Among these groups direct angiosomal “source-artery” revascularization (WTR) was feasible in 113 (60%) of the treated limbs. Starting from a zero point for tissue recovery, healing rate was 80% (+/-7) at 12 months in the A, 78% (+/-13%) in the B, and 47% (+/-13%) in the C Group at the same time intervals. Healing comparison between Groups A and B was non-significant (p=0.087, HR=1.47) while comparing the A with the C Group (p=0.0081, HR=0.44), and the B with the C Group (p=0.0005, HR=0.30), significant differences became apparent. The major adverse limb events (MALE) and limb salvage characteristics between A and B (p=0.027, and p=0.035), and A versus C Groups (p=0.0068, and p=0.0061) also appeared significant. Same parameters comparison between B and C cohorts yet showed no meaningful differences (p=0.959, and p=0.756). No dissimilarities in survival were observed.

Conclusion
WTR for diabetic neuro-ischemic foot ulcers improved the healing rates, when technically achievable. Although limb salvage and MALE also appeared enhanced by regional direct revascularization, no statistical difference was found between collateral-oriented and collateral-indifferent types of reperfusions. WIR may remain a valid option for limb salvage in about one quarter of patients.

Since its first formulation by Taylor and Palmer1 in 1987, the angiosome concept continues to inspire researchers to add new applications in various therapeutic fields.1,2 Particularly in critical limb ischemia (CLI) treatment, there is mounting contemporary evidence that novel AC applications produce better ischemic tissue regeneration and limb preservation.2–8 Parallel to unremitting pro- gress in vascular technology, new insights concerning either bypass or endovascular therapy are now available based on the concept of ‘‘wound-directed’’ revasculariza- tion.3–9 The article by Iida et al.10 in this issue of the JEVT represents one of these gradual steps toward wider comprehension of the mechanisms and related treatments that have evolved for CLI in recent years.8,9

Outstanding scientific advances over the last decades unceasingly reveal real complexity of wound-healing process, astonishing in its staged progression, as life is unfolding itself. This natural course of tissue repair seems to bear thousands of overlapping molecular and macroscopic processes that nowadays only start to unfold to our knowledge. The present volume collecting recent scientific references proposes to readers a two-folded audacious goal. First, an updated design of intimate cellular mechanisms is entailed in tissue regeneration that emanates from the first section of the book. Next, a multidisciplinary therapeutic perspective that focuses on macroscopic healing throughout the second part of this work adds clinically integrated observation. Practical diagnostic and treatment information is appended in each chapter that may equally help experienced clinicians or dedicated students and researchers in broadening essential breaking points of their work. It is the wish of all multidisciplinary experts who gather prominent author's panel of this volume to incorporate latest medical reports and compel limits of current understanding for better tissue regeneration, limb salvage, and improved quality of life of our patients.

Edited by Vlad Adrian Alexandrescu, ISBN 978-953-51-2679-9, Print ISBN 978-953-51-2678-2, 546 pages, Publisher: InTech, Chapters published October 12, 2016 under CC BY 3.0 license
DOI: 10.5772/61906

During the recent decades soaring progresses in vascular disease knowledge, particularly in critical limb ischemia (CLI) treatment enhanced novel diagnostic and interventional strategies with high serviceableness in patient’s selection, arterial recanalization, and dedicated ischemic ulcer follow-up. However, despite undeniable advances in medical technology and clinical judgment, limb salvage, the ambulation recovery and patient’s survival, seem only scarcely affected in this heterogeneous CLI group, particularly concerning the diabetic and renal patients. Innovative strategies such as “end artery occlusive disease” treatment or “wound-targeted revascularization” were equally proposed, by following the angiosomal anatomical distribution associating individual foot collateral assessment in an unified macro- and micro-circulatory judgment. However, despite encouraging clinical results, prospective evidence still lacks on this concern. It also appears that specific wounds could not always stand for the lowest perfusion areas according to current CLI criteria, since severe neuropathy, inflammatory swelling, local infection and skin trauma may add complementary hindrances to tissue viability.