Results of Infrapopliteal Endovascular Procedures Performed in Diabetic Patients with Critical Limb Ischemia and Tissue Loss from the Perspective of an Angiosome-Oriented Revascularization Strategy
Our aim was to describe our experience with infrapopliteal endovascular procedures performed in diabetic patients with ischemic ulcers and critical ischemia (CLI). A retrospective study of 101 procedures was performed. Our cohort was divided into groups according to the number of tibial vessels attempted and the number of patent tibial vessels achieved to the foot. An angiosome anatomical classification of ulcers were used to describe the local perfusion obtained after revascularization. Ischemic ulcer healing and limb salvage rates were measured. Ischemic ulcer healing at 12 months and limb salvage at 24 months was similar between a single revascularization and multiple revascularization attempts. The group in whom none patent tibial vessel to the foot was obtained presented lower healing and limb salvage rates. No differences were observed between obtaining a single patent tibial vessel versus more than one tibial vessel. Indirect revascularization of the ulcer through arterial-arterial connections provided similar results than those obtained after direct revascularization via its specific angiosome tibial artery. Our results suggest that, in CLI diabetic patients with ischemic ulcers that undergo infrapopliteal endovascular procedures, better results are expected if at least one patent vessel is obtained and flow is restored to the local ischemic area of the foot. 1. Introduction Critical limb ischemia (CLI) mainly affects elderly patients with important comorbidities and significant diffuse multilevel vascular lesions [1, 2]. These patients are frequently diabetics with neuroischemic limb ulcers, gangrene, and foot sepsis. This specific group is prone to develop an aggressive form of the disease, with more tibial affectation and microcirculatory impairment [3, 4]. The risk of limb loss is higher among diabetics and in patients with ischemic ulcers [1, 2]. In the absence of a successful revascularization, major amputation and mortality rates of CLI patients are substantial. In this context, obtaining at least one patent tibial artery to the foot is usually needed to achieve a sufficient amount of blood flow to cover the healing process requirements and ensure limb salvage [5–9]. Therefore, infrainguinal revascularization procedures are frequently performed, especially on tibial vessels. According to several studies, tibial endovascular techniques could provide similar clinical outcomes as distal vein bypass surgery with a lower rate of procedure-related complications [10–12]. In many centres, these interventions have been implemented as first line of
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