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

  • Hae Won Jung
    Affiliations
    Department of Cardiology, Daegu Catholic University Medical Centre, Daegu, Republic of Korea
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  • Young-Guk Ko
    Correspondence
    Corresponding author. Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea.
    Affiliations
    Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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  • Sung-Jin Hong
    Affiliations
    Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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  • Chul-Min Ahn
    Affiliations
    Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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  • Jung-Sun Kim
    Affiliations
    Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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  • Byeong-Keuk Kim
    Affiliations
    Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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  • Donghoon Choi
    Affiliations
    Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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  • Myeong-Ki Hong
    Affiliations
    Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea

    Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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  • Yangsoo Jang
    Affiliations
    Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea

    Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Open ArchivePublished:October 22, 2019DOI:https://doi.org/10.1016/j.ejvs.2019.07.034

      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 < .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 >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.

      Keywords

      Pedal arch patency has been associated with improved wound healing after revascularisation. However, limited data exist regarding the impact of endovascular pedal artery revascularisation (PAR) on clinical outcomes of patients with critical limb ischaemia (CLI). This study demonstrates that successful PAR in patients with CLI achieved higher rates of wound healing and freedom from major amputation than infrapopliteal revascularisation without PAR. Thus, efforts should be made to revascularise the pedal arteries, especially when the pedal arch is completely absent in patients with CLI.

      Introduction

      Revascularisation is the cornerstone of critical limb ischaemia (CLI) treatment for lower limb preservation. Endovascular revascularisation is the favoured approach in many centres because of its lower morbidity and mortality than open surgery.
      • Shishehbor M.H.
      • White C.J.
      • Gray B.H.
      • Menard M.T.
      • Lookstein R.
      • Rosenfield K.
      • et al.
      Critical limb ischemia: an expert statement.
      Recent studies have suggested that direct revascularisation of an ischaemic wound area based on the angiosome concept produces better wound healing than indirect revascularisation.
      • Alexandrescu V.A.
      • Hubermont G.
      • Philips Y.
      • Guillaumie B.
      • Ngongang C.
      • Vandenbossche P.
      • et al.
      Selective primary angioplasty following an angiosome model of reperfusion in the treatment of Wagner 1-4 diabetic foot lesions: practice in a multidisciplinary diabetic limb service.
      • Iida O.
      • Soga Y.
      • Hirano K.
      • Kawasaki D.
      • Suzuki K.
      • Miyashita Y.
      • et al.
      Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions.
      • Bosanquet D.C.
      • Glasbey J.C.
      • Williams I.M.
      • Twine C.P.
      Systematic review and meta-analysis of direct versus indirect angiosomal revascularisation of infrapopliteal arteries.
      However, the effectiveness of angiosome based revascularisation strategies is controversial. Most previous studies were retrospective, and their comparative groups were not well controlled.
      • Sumpio B.E.
      • Forsythe R.O.
      • Ziegler K.R.
      • van Baal J.G.
      • Lepantalo M.J.
      • Hinchliffe R.J.
      Clinical implications of the angiosome model in peripheral vascular disease.
      • Bunte M.C.
      • Shishehbor M.H.
      Angiosome-guided intervention in critical limb ischemia.
      Other investigators suggested that the revascularisation of multiple infrapopliteal vessels instead of a single angiosome related artery might be more advantageous for wound healing and limb salvage.
      • Biagioni R.B.
      • Biagioni L.C.
      • Nasser F.
      • Burihan M.C.
      • Ingrund J.C.
      • Neser A.
      • et al.
      Infrapopliteal angioplasty of one or more than one artery for critical limb ischaemia: a randomised clinical trial.
      • Ambler G.K.
      • Stimpson A.L.
      • Wardle B.G.
      • Bosanquet D.C.
      • Hanif U.K.
      • Germain S.
      • et al.
      Infrapopliteal angioplasty using a combined angiosomal reperfusion strategy.
      • Kobayashi N.
      • Hirano K.
      • Yamawaki M.
      • Araki M.
      • Takimura H.
      • Sakamoto Y.
      • et al.
      Clinical effects of single or double tibial artery revascularization in critical limb ischemia patients with tissue loss.
      The quality of the pedal arch is also considered to be an important factor affecting perfusion of ischaemic areas in the distal lower limb.
      • Kawarada O.
      • Fujihara M.
      • Higashimori A.
      • Yokoi Y.
      • Honda Y.
      • Fitzgerald P.J.
      Predictors of adverse clinical outcomes after successful infrapopliteal intervention.
      • Rashid H.
      • Slim H.
      • Zayed H.
      • Huang D.Y.
      • Wilkins C.J.
      • Evans D.R.
      • et al.
      The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome.
      The pedal arch connects the anterior and posterior circulation of the foot and is the main blood supply to the forefoot. Pedal arch patency has been associated with improved wound healing after revascularisation.
      • Kawarada O.
      • Fujihara M.
      • Higashimori A.
      • Yokoi Y.
      • Honda Y.
      • Fitzgerald P.J.
      Predictors of adverse clinical outcomes after successful infrapopliteal intervention.
      • Rashid H.
      • Slim H.
      • Zayed H.
      • Huang D.Y.
      • Wilkins C.J.
      • Evans D.R.
      • et al.
      The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome.
      • Troisi N.
      • Turini F.
      • Chisci E.
      • Ercolini L.
      • Frosini P.
      • Lombardi R.
      • et al.
      Pedal arch patency and not direct-angiosome revascularization predicts outcomes of endovascular interventions in diabetic patients with critical limb ischemia.
      However, limited data exist regarding the impact of endovascular pedal artery revascularisation (PAR) on the clinical outcomes of patients with CLI. In the present study, the effects of endovascular revascularisation of the pedal arteries on wound healing in patients with CLI due to chronic infrapopliteal arterial disease and incomplete pedal arch was investigated.

      Materials and methods

      Study population

      The electronic medical records of 415 patients who underwent endovascular treatment for chronic infrapopliteal arterial disease at Severance Cardiovascular Hospital, Yonsei University Health System, from January 2009 to December 2016, were evaluated retrospectively. Patients without CLI (n = 40) or a lower extremity wound (Rutherford category 4, n = 70); patients with Buerger disease (n = 30), previous bypass surgery (n = 18), or an intact pedal arch (type 1, n = 4); and patients lost to follow up after discharge (n = 14) were excluded. The final analysis included 239 patients with 239 target limbs (Fig. 1). All included patients had Rutherford category 5 or 6 CLI and a pre-procedural pedal arch classified as type 2 or 3. Pedal arch types were classified into type 1 (both the dorsalis pedis and lateral plantar arteries were patent), type 2 (either the dorsalis pedis artery or the lateral plantar artery was patent), and type 3 (neither the dorsalis pedis artery nor the lateral plantar artery were patent) (Fig. 2).
      • Kawarada O.
      • Fujihara M.
      • Higashimori A.
      • Yokoi Y.
      • Honda Y.
      • Fitzgerald P.J.
      Predictors of adverse clinical outcomes after successful infrapopliteal intervention.
      Patients were evaluated before endovascular revascularisation by physical examination, ankle brachial index (ABI), and an imaging study, such as a computed tomography (CT) scan or colour Duplex ultrasound. The wounds were primarily examined and treated by orthopaedic surgeons. Data were collected regarding baseline medical history, medications, revascularisation procedure, and immediate and late outcomes. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki. The Institutional Review Board approved the study and waived the requirement for patient informed consent because of the study's retrospective nature.
      Figure 1
      Figure 1Patient flowchart. CLI = critical limb ischaemia.
      Figure 2
      Figure 2Pedal arch types: (A) type 1, both the dorsalis pedis and plantar arteries are patent; (B) type 2, either the dorsalis pedis artery or the plantar artery is patent; and (C) type 3, neither the dorsalis pedis artery nor the plantar artery is patent.

      Interventional procedure

      All procedures were performed under local anaesthesia, supplemented by intravenous sedation and analgesia. Depending on the presence of combined proximal lesions, an ipsilateral antegrade approach or a contralateral crossover approach was chosen. For the ipsilateral antegrade approach, a 5 F or 6 F Ansel sheath (Cook, Bloomington, IN, USA) was introduced into the popliteal artery through the ipsilateral common femoral artery; for the contralateral crossover approach, a 6 F–8 F Balkin sheath (Cook) or 5 F or 6 F Shuttle sheath (Cook) was inserted through the contralateral femoral artery. After insertion of the sheath, unfractionated heparin (5000 units) was administered to achieve an activated clotting time of >250 s. When present, significant proximal inflow lesions were treated in the same session before endovascular treatment of the infrapopliteal lesions. For treatment of the infrapopliteal lesions, a 0.014, 0.018, or 0.035 inch guidewire plus microcatheters or supporting catheters were used via an intraluminal approach or a subintimal approach, depending on the lesion's characteristics and operator's preference. When antegrade wire passage in the tibial or peroneal arteries failed, a retrograde approach via pedal puncture, pedal plantar loop technique, or transcollateral wiring was performed. The pedal plantar loop technique refers to the creation of a loop from the dorsalis pedis artery to the lateral plantar circulation or vice versa by means of the guidewire and balloon tracking through the plantar arch of the foot.
      • Fusaro M.
      • Dalla Paola L.
      • Biondi-Zoccai G.
      Pedal-plantar loop technique for a challenging below-the-knee chronic total occlusion: a novel approach to percutaneous revascularization in critical lower limb ischemia.
      The transcollateral technique is based on the retrograde recanalisation of the occluded tibial arteries by guidewire tracking through the collaterals between the different tibial arteries.
      • Fusaro M.
      • Agostoni P.
      • Biondi-Zoccai G.
      Trans-collateral" angioplasty for a challenging chronic total occlusion of the tibial vessels: a novel approach to percutaneous revascularization in critical lower limb ischemia.
      The decision to perform multivessel revascularisation or PAR was left to the discretion of the operators. In general, the treatment goal was to obtain at least one straight line blood flow to the ischaemic territory. In patients with ischaemic wounds, an attempt was made to revascularise as many tibial and pedal arteries as possible, whenever feasible. Wire passage for PAR was primarily performed using an antegrade approach. However, when antegrade wiring failed, retrograde wire passage by the pedal plantar loop technique was attempted. All infrapopliteal lesions were treated by angioplasty using 2–4 mm diameter balloon catheters. In the presence of flow limiting dissection despite multiple balloon dilations, bailout stenting was performed with a self panding bare metal stent of 3–4 mm diameter and 60–80 mm length (Maris Deep; Medtronic, Minneapolis, MN, USA). Drug eluting stents and drug eluting balloons were not available for infrapopliteal lesions. No stents were implanted below the ankle. After successful recanalisation, the patients generally received a combination of aspirin (100 mg/day) and either clopidogrel (75 mg/day) or cilostazol (200 mg/day) for at least one year.

      Post-procedural follow up

      After the procedure, the patients were followed by orthopaedic surgeons or cardiologists at one month intervals until wound healing was complete. After complete wound healing, clinical follow up was scheduled every three to six months. Follow up ABI was routinely performed before discharge from hospital and at six and 12 months after the procedure. A follow up imaging study using duplex ultrasound or CT angiography was performed in patients with symptoms or worsening wounds.

      Study end points and definitions

      The primary end point was the rate of wound healing 12 months after the index endovascular procedure. The secondary end points included overall survival, freedom from major amputation, major adverse limb event (MALE), and freedom from re-intervention. Wound healing was defined as complete epithelialisation of all wounds without major amputation. Major amputation was defined as an above ankle amputation. MALE was defined as a major amputation or any surgical or endovascular re-intervention according to the Peripheral Academic Research Consortium.
      • Patel M.R.
      • Conte M.S.
      • Cutlip D.E.
      • Dib N.
      • Geraghty P.
      • Gray W.
      • et al.
      Evaluation and treatment of patients with lower extremity peripheral artery disease: consensus definitions from Peripheral Academic Research Consortium (PARC).
      Direct flow was considered present when an angiosome based straight line to the wound was achieved by endovascular therapy. The previously described definition of angiosome based recanalisation was adopted.
      • Iida O.
      • Soga Y.
      • Hirano K.
      • Kawasaki D.
      • Suzuki K.
      • Miyashita Y.
      • et al.
      Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions.
      According to the angiosome concept, the anterior tibial artery supplies the dorsal aspect of the toe and dorsal foot; the posterior tibial artery supplies the plantar aspect of the toe, web space of the toes, plantar foot, and the inside of the heel; and the peroneal artery supplies lateral ankle and the outside of the heel. All wounds were assessed using the Rutherford classification system and the Wound, Ischaemia, and foot Infection (WIfI) classification. Rutherford category 5 was defined as minor tissue loss. Rutherford category 6 was defined as major tissue loss extending above the transmetatarsal level. Detailed definitions of the WIfI system have been described in the literature.
      • Mills Sr., J.L.
      • Conte M.S.
      • Armstrong D.G.
      • Pomposelli F.B.
      • Schanzer A.
      • Sidawy A.N.
      • et al.
      The society for vascular surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI).

      Statistical analysis

      Data are expressed as n (%) or mean ± standard deviation (SD). Baseline characteristics and procedural data were compared between the PAR and the non-PAR groups using the Student's t test and the chi square test as appropriate. Propensity score matching was performed to reduce selection bias and potential confounder effects and create balanced groups. The following variables were used for matching: age, sex, hypertension, diabetes mellitus, chronic kidney disease, body mass index, baseline lipid profiles, and current medication (anticoagulant, antiplatelet, and number of antihypertensive agents). After matching, validation was performed according to the standardised mean difference of all baseline covariates, using a threshold of 0.1 to indicate imbalance.
      The rates of wound healing and “freedom from” secondary end points were analysed using the Kaplan–Meier method and compared among patient subgroups using the log rank test.
      Univariable analyses using Cox proportional hazards regression, including baseline clinical and procedural data, were performed to determine factors associated with wound healing. Those variables achieving a p value < .15 in univariable analysis were entered into a multivariable model to determine the independent predictors for wound healing. P values < .05 were considered statistically significant. All analyses were performed using SPSS for Windows, version 23 (IBM, Armonk, NY, USA).

      Results

      Baseline clinical and lesion data

      The enrolled patients were mostly male (76.2%), with a mean age of 67.2 ± 10.3 years. Diabetes mellitus and dialysis dependent end stage renal disease were present in 86.2% and 32.3% of patients, respectively. The majority of patients (77.0%) had a Rutherford category of 5. The wounds were located primarily in the toes (77.0%). An infected wound was present in 28.5% of patients. Most infrapopliteal target lesions were total occlusions (72.4%) and longer than 20 cm (85.8%).
      PAR was attempted in 141 patients during the infrapopliteal artery interventions. In the other 98 patients, the infrapopliteal angioplasty was limited to the above ankle level. The PAR patient group showed more multiple infrapopliteal target vessels than the non-PAR group (68.1% vs. 54.1; p = .028). In addition, there were trends toward a higher frequency of gangrenous wounds (53.9% vs. 41.8%; p = .067), wound infection (32.6% vs. 22.4%; p = .086), and anterior tibial artery (85.8% vs. 76.5%; p = .066) as a target vessel in the PAR group than in the non-PAR group. Other characteristics were similar between the two groups.
      After one to one propensity score matching, a total of 87 patient pairs who showed no significant differences in baseline clinical and lesion characteristics were obtained. The baseline clinical and lesion characteristics of the PAR and the non-PAR groups before and after propensity score matching (PSM) are summarised in Table 1.
      Table 1Baseline clinical characteristics before and after propensity score matching
      Before matchingAfter matching
      PAR (n = 141)Non-PAR (n = 98)p valuePAR (n = 87)Non-PAR (n = 87)p value
      Male sex109 (77.3)73 (74).61564 (74)65 (75).863
      Age, y67.2 ± 10.567.4 ± 10.3.86967.1 ± 10.967.8 ± 9.4.668
      BMI, kg/m222.4 ± 3.622.7 ± 3.3.49522.3 ± 3.922.5 ± 3.3.632
      Hypertension105 (74.5)74 (75).85564 (74)65 (75).863
      Diabetes mellitus120 (85.1)86 (88).55974 (85)76 (87).660
      Hypercholesterolaemia60 (42.6)47 (48).40837 (42)42 (48).446
      CKD55 (39.0)45 (46).28734 (39)40 (46).358
      ESRD43 (30.5)34 (35).49528 (32)31 (36).631
      CAD51 (36.2)46 (47).09537 (42)39 (45).760
      Stroke15 (10.6)7 (7).3588 (9)7 (8).787
      Smoking72 (51.1)52 (53).76142 (48)49 (56).288
      Previous angioplasty36 (25.5)22 (22).58521 (24)18 (21).585
      Rutherford category.651.858
       5110 (78.0)74 (75)67 (77)66 (76)
       631 (22.0)24 (24)20 (23)21 (24)
      Wound character.067.648
       Ulcer65 (46.1)57 (58)45 (52)48 (55)
       Gangrene76 (53.9)41 (42)42 (48)39 (45)
      Wound location.545.505
       Toes111 (78.7)73 (74)70 (80)68 (78)
       Dorsal4 (2.8)5 (5)2 (2)4 (5)
       Plantar2 (1.4)2 (2)0 (0)2 (2)
       Heel13 (9.2)5 (5)8 (9)4 (5)
       Above ankle1 (0.7)1 (1)1 (1)1 (1)
       Multiple10 (7.1)12 (12)6 (7)8 (9)
      Wound infection46 (32.6)22 (22).08621 (24)21 (24)1
      WIfI score3.6 ± 1.43.5 ± 1.7.6293.6 ± 1.43.5 ± 1.6.694
      WIfI score ≥ 533 (23.4)25 (25).70921 (24)22 (25).860
      CRP > 3 mg/L37 (26.2)26 (26).96023 (26)24 (27).864
      Medication at discharge
       Aspirin121 (85.8)77 (78).14475 (86)70 (80).309
       Clopidogrel116 (82.3)81 (83).93971 (82)71 (82)1
       Aspirin + clopidogrel99 (70.2)67 (68).81360 (69)61 (70).869
       Cilostazol31 (22.0)25 (25).52723 (26)21 (24).727
       Statin98 (69.5)73 (74).40165 (75)64 (74).863
      Data are n (%) or mean ± standard deviation. PAR = pedal artery revascularization; BMI = body mass index; CKD = chronic kidney disease; ESRD = end stage renal disease; CAD = coronary artery disease; WIfI = Wound, Ischaemia, and foot Infection; CRP = C reactive protein.

      Procedural data

      Procedural data before and after PSM are presented in Table 2. Angiosome based direct flow was obtained more frequently in the PAR group than in the non-PAR group (81.6% vs. 33.3%; p < .001 between the matched groups). Successful PAR was achieved in 60.9% of the matched PAR group. Subintimal angioplasty (47.1% vs. 29.9%; p = .019) and pedal plantar loop technique (18.4% vs. 0%; p < .001) were more frequently adopted in the PAR group. The PAR group also showed a trend towards a higher rate of tibial bailout stenting (13.8 vs. 5.7; p = .074). As a result of successful PAR, there were more type 2 pedal arches (39.1% vs. 0%) and fewer type 3 pedal arches (13.8% vs. 36.8%) in the PAR group than in the non-PAR group (p < .001). However, post-procedural ABI was similar between the two groups. Procedural complications also did not differ between the PAR and the non-PAR groups.
      Table 2Lesion and procedural data
      Before matchingAfter matching
      PAR (n = 141)Non-PAR (n = 98)p valuePAR (n = 87)Non-PAR (n = 87)p value
      Number of runoff vessels.359.641
       055 (39.0)57 (58)55 (63)51 (59)
       1 or 254 (38.3)41 (42)32 (37)36 (41)
      Total occlusion103 (73.0)70 (71).78362 (71)61 (70).868
      Lesion length, cm30.2 ± 12.528.8 ± 12.7.40330.0 ± 13.028.9 ± 12.7.541
      Lesion length > 20 cm123 (87.2)82 (84).43876 (87)73 (84).517
      TASC lesion type D128 (90.8)90 (92).77778 (90)0 (92).600
      Infrapopliteal target vessel
       Anterior tibial artery121 (85.8)75 (76).06673 (84)87 (79).434
       Posterior tibial artery90 (63.8)53 (54).13150 (57)46 (53).542
       Peroneal artery33 (23.4)26 (26).58119 (22)22 (25).592
      Multiple infrapopliteal target vessels96 (68.1)53 (54).02852 (60)48 (55).540
      Combined proximal procedure44 (31.2)40 (41).12630 (35)36 (41).349
      Subintimal approach62 (44.0)29 (29).02441 (47)26 (30).019
      Pedal–plantar loop technique26 (18.4)0 (0).00116 (18)0 (0)<.001
      Transpedal approach0 (0)1 (1).4100 (0)0 (0)
      Transcollateral approach0 (0)2 (2).1670 (0)2 (2).497
      Tibial bailout stenting19 (13.5)5 (5).03412 (14)5 (6).074
      Successful PAR89 (63)53 (61)
      Direct angiosome direct116 (82.3)32 (33)<.00171 (82)29 (33)<.001
      Pre-pedal arch type.722.534
       286 (61.0)62 (63)51 (59)55 (63)
       355 (39.0)36 (37)36 (41)32 (37)
      Post-pedal arch type<.001<.001
       158 (41.1)0 (0)34 (39)0 (0)
       266 (46.8)62 (63)41 (47)55 (63)
       317 (12.1)36 (37)12 (14)32 (37)
      Pre-ABI0.74 ± 0.310.62 ± 0.25.0140.66 ± 0.270.63 ± 0.24.576
      Post-ABI0.90 ± 0.220.85 ± 0.22.1840.88 ± 0.220.86 ± 0.22.611
      Complications
       Puncture site haematoma6 (4.3)5 (5).9953 (3)4 (5)1
       Vascular rupture5 (3.5)6 (6).3532 (2)6 (7).152
       Flow limiting distal embolisation or dissection0 (0)0 (0)0 (0)0 (0)
       Complications requiring surgery1 (0.7)1 (1)10 (0)1 (1)1
      Data are n (%) or mean ± standard deviation. PAR = pedal artery revascularization; TASC = The Inter-Society Consensus for the Management of Peripheral Arterial Disease; ABI = ankle brachial index.

      Late outcomes

      Patients were followed for a median of 644 days. The one year clinical outcomes of PAR and non-PAR groups are shown in Table 3. Overall survival did not differ significantly before or after PSM. Freedom from major amputation was significantly higher in the PAR group than in the non-PAR group before PSM (96.1% vs. 84.0%; p = .001), as well as after PSM (96.3% vs. 84.2%; p = .009) (Table 3, Fig. 3). Freedom from MALE was significantly higher in the PAR group before PSM (80.5% vs. 70.3%; p = .042). However, after PSM, there was no significant difference between the two groups (75.7% vs. 72.6%; p = .418). Freedom from re-intervention did not differ significantly before or after PSM. However, there was a trend towards lower freedom from re-intervention in the PAR group after PSM (79.2% vs. 88.0%; p = .174). In the matched groups, there were three and 13 major amputations in the PAR and the non-PAR group, respectively. All major amputations occurred within one year, none of which was planned prior to the index procedure. The time to major amputations was 77.7 ± 73.1 days in the PAR group and 57.2 ± 98.5 days in the non-PAR group. None of the patients who underwent major amputations required re-interventions.
      Table 3Comparison of clinical outcomes at one year between the pedal artery revascularisation (PAR) and the non-PAR groups before and after propensity score matching
      Before matching (%)After matching (%)
      PAR (n = 141)Non-PAR (n = 98)p valuePAR (n = 87)Non-PAR (n = 87)p value
      Overall survival9190.7939090.739
      Freedom from major amputation9684.0019684.009
      Freedom from MALE8170.0427673.418
      Freedom from re-intervention8386.6177988.174
      Wound healing7470.0887067.130
      MALE = major adverse limb event.
      Figure 3
      Figure 3Kaplan–Meier curves for wound healing (A, unmatched population; C, matched population) and freedom from major amputation (B, unmatched population; D, matched population). PAR = pedal artery revascularisation.
      The PAR group showed a trend towards higher wound healing rate than the non-PAR group before the PSM (74.4% vs. 69.8%; p = .088) and after the PSM (70.3% vs. 67.0%; p = .130) (Table 3, Fig. 3). In the patient subgroup with successful PAR, the wound healing rate was significantly higher than in the non-PAR group (76.0% vs. 67.0%; p = .031).
      The wound healing rate was significantly lower in patients with pre-procedural type 3 pedal arch than in patients with pre-procedural type 2 (p = .027; Fig. 4A) and lower in patients with post-procedural type 3 pedal arch than in patients with post-procedural type 1 or type 2 (p = .001; Fig. 4B).
      Figure 4
      Figure 4Kaplan–Meier curves for wound healing according to (A) pre-procedural and (B) post-procedural pedal arch types.
      In a multivariable Cox proportional hazards regression model, successful PAR (hazard ratio [HR] 1.564, 95% confidence interval [CI] 1.068–2.29; p = .022) was identified as an independent factor associated with improved wound healing, whereas gangrene (HR 0.659, 95% CI 0.471–0.923; p = .015), C reactive protein (CRP) > 3 mg/dL (HR 0.591, 95% CI 0.386–0.904; p = .015), and pre-procedural type 3 pedal arch (HR 0.628, 95% CI 0.431–0.916; p = .016) were associated with impaired wound healing (Table 4).
      Table 4Univariable and multivariable Cox proportional hazards regression analyses of factors associated with wound healing
      FactorUnivariable analysis – HR (95% CI)p valueMultivariable analysis – HR (95% CI)p value
      Age1.010 (0.993–1.027).237
      Male0.876 (0.591–1.299).511
      BMI1.984 (0.879–1.102).785
      DM0.725 (0.452–1.164).183
      Hypertension0.757 (0.524–1.093).1370.772 (0.530–1.125).177
      Dyslipidaemia0.971 (0.699–1.349).863
      ESRD0.822 (0.575–1.175).282
      Smoking0.868 (0.627–1.203).396
      Previous angioplasty0.855 (0.580–1.261).617
      Previous amputation0.935 (0.651–1.343).715
      Rutherford category 61.096 (0.740–1.624).648
      Gangrene0.642 (0.461–0.893).0080.659 (0.471–0.923).015
      WIfI score ≥ 50.757 (0.495–1.158).199
      Wound location other than toes0.863 (0.568–1.311).490
      Infected wound1.100 (0.766–1.579).608
      CRP > 3 mg/dL0.996 (0.990–1.001).1230.591 (0.386–0.904).015
      Total occlusion0.804 (0.566–1.141).222
      Lesion length > 200 mm1.173 (0.738–1.864).499
      Multiple infrapopliteal target vessels0.980 (0.696–1.382).910
      Inflow target lesions0.962 (0.682–1.357).827
      No runoff vessel0.575 (0.142–2.321).437
      Pre-ABI1.471 (0.777–2.784).236
      Post-ABI1.022 (0.394–2.649).964
      Pre-type 3 pedal arch0.668 (0.470–0.950).0250.628 (0.431–0.916).016
      Pedal artery revascularisation
       Attempted1.356 (0.912–2.015).133
       Successful1.499 (1.078–2.084).0161.564 (1.068–2.290).022
      Direct flow1.363 (0.958–1.939).0851.127 (0.747–1.699).570
      Dual antiplatelet therapy1.129 (0.792–1.610).501
      Cilostazol1.003 (0.686–1.468).986
      Statin1.018 (0.709–1.461).925
      HR = hazard ratio; CI = confidence interval; BMI = body mass index; DM = diabetes mellitus; ESRD = end stage renal disease; WIfI = Wound, Ischaemia, and foot Infection; CRP = C reactive protein; ABI = ankle brachial index.

      Discussion

      Successful endovascular revascularisation of the pedal arteries achieved higher rates of wound healing and major amputation free survival. Absence of a patent pedal arch before, and especially after, endovascular therapy was associated with poor wound healing. Gangrene, high CRP (>3 mg/L), type 3 pedal arch before the procedure, and successful PAR were independent factors associated with wound healing.
      In patients with CLI, the majority of vascular lesions are located below the knee.
      • Graziani L.
      • Silvestro A.
      • Bertone V.
      • Manara E.
      • Andreini R.
      • Sigala A.
      • et al.
      Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity.
      • Ko Y.G.
      • Ahn C.M.
      • Min P.K.
      • Lee J.H.
      • Yoon C.H.
      • Yu C.W.
      • et al.
      Baseline characteristics of a retrospective patient cohort in the Korean vascular intervention society endovascular therapy in lower limb artery diseases (K-VIS ELLA) registry.
      In the last decade, endovascular therapy has evolved considerably as a result of advances in procedural techniques and devices, and has demonstrated favourable clinical outcomes in patients with CLI. In general, endovascular therapy has been associated with lower primary patency but similar wound healing and freedom from major amputation, when compared with bypass surgery.
      • Adam D.J.
      • Beard J.D.
      • Cleveland T.
      • Bell J.
      • Bradbury A.W.
      • Forbes J.F.
      • et al.
      Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial.
      • Schamp K.B.
      • Meerwaldt R.
      • Reijnen M.M.
      • Geelkerken R.H.
      • Zeebregts C.J.
      The ongoing battle between infrapopliteal angioplasty and bypass surgery for critical limb ischemia.
      Because of its lower morbidity, endovascular therapy has become the preferred first line treatment in many centres.
      The angiosome concept was proposed as a strategy for the revascularisation of infrapopliteal arteries.
      • Attinger C.E.
      • Evans K.K.
      • Bulan E.
      • Blume P.
      • Cooper P.
      Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization.
      An angiosome is a block of tissue supplied by a specific artery, which consists of the skin, subcutaneous tissue, fascia, muscle, and bone.
      • Taylor G.I.
      • Palmer J.H.
      The vascular territories (angiosomes) of the body: experimental study and clinical applications.
      According to wound location, the arteries supplying the corresponding angiosome are considered the primary targets for revascularisation. Several studies have demonstrated that direct revascularisation of the ischaemic area based on the angiosome concept produced superior outcomes during endovascular therapy, when compared with indirect revascularisation.
      • Alexandrescu V.A.
      • Hubermont G.
      • Philips Y.
      • Guillaumie B.
      • Ngongang C.
      • Vandenbossche P.
      • et al.
      Selective primary angioplasty following an angiosome model of reperfusion in the treatment of Wagner 1-4 diabetic foot lesions: practice in a multidisciplinary diabetic limb service.
      • Iida O.
      • Soga Y.
      • Hirano K.
      • Kawasaki D.
      • Suzuki K.
      • Miyashita Y.
      • et al.
      Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions.
      • Bosanquet D.C.
      • Glasbey J.C.
      • Williams I.M.
      • Twine C.P.
      Systematic review and meta-analysis of direct versus indirect angiosomal revascularisation of infrapopliteal arteries.
      However, the usefulness of the angiosome concept remains controversial. Correlations between angiosome based direct revascularisation and lower limb outcomes were not consistently observed in other studies, similar to the current study.
      • Rashid H.
      • Slim H.
      • Zayed H.
      • Huang D.Y.
      • Wilkins C.J.
      • Evans D.R.
      • et al.
      The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome.
      • Azuma N.
      • Uchida H.
      • Kokubo T.
      • Koya A.
      • Akasaka N.
      • Sasajima T.
      Factors influencing wound healing of critical ischaemic foot after bypass surgery: is the angiosome important in selecting bypass target artery?.
      • Nakama T.
      • Watanabe N.
      • Haraguchi T.
      • Sakamoto H.
      • Kamoi D.
      • Tsubakimoto Y.
      • et al.
      Clinical outcomes of pedal artery angioplasty for patients with ischemic wounds: results from the multicenter RENDEZVOUS registry.
      • Acin F.
      • Varela C.
      • Lopez de Maturana I.
      • de Haro J.
      • Bleda S.
      • Rodriguez-Padilla J.
      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.
      Furthermore, definitions of foot angiosomes vary.
      • Spillerova K.
      • Biancari F.
      • Settembre N.
      • Alback A.
      • Venermo M.
      The prognostic significance of different definitions for angiosome-targeted lower limb revascularization.
      Owing to dual arterial supply of the heel and digits, it is difficult to define the direct revascularisation.
      • Spillerova K.
      • Biancari F.
      • Settembre N.
      • Alback A.
      • Venermo M.
      The prognostic significance of different definitions for angiosome-targeted lower limb revascularization.
      Interestingly Rother et al.
      • Rother U.
      • Krenz K.
      • Lang W.
      • Horch R.E.
      • Schmid A.
      • Heinz M.
      • et al.
      Immediate changes of angiosome perfusion during tibial angioplasty.
      investigated pedal tissue perfusion after tibial artery angioplasty and found that improvement of tissue perfusion was global and not restricted to certain borders, such as those defined by angiosomes. This result suggests that chronic ischaemia of the foot leads to significant collateralisation between angiosomes, which may result in re-organisation of the angiosome borders. The Global Vascular Guidelines on the Management of Chronic Limb Threatening Ischaemia
      • Higashimori A.
      • Iida O.
      • Yamauchi Y.
      • Kawasaki D.
      • Nakamura M.
      • Soga Y.
      • et al.
      Outcomes of one straight-line flow with and without pedal arch in patients with critical limb ischemia.
      recommends angiosome guided revascularisation in patients with significant wounds, particularly those involving the mid- or hindfoot. However, the guidelines consider angiosome guided revascularisation irrelevant for toe lesions. In accordance with this, in the present study, where the majority (77%) of the ischaemic wounds were toe lesions, angiosome based direct revascularisation was not associated with improved wound healing.
      The quality of the pedal arch is also regarded as an important factor for foot circulation because the pedal arch connects the anterior and posterior circulations and is the main blood supply for the entire distal forefoot. Kawarada et al.
      • Kawarada O.
      • Fujihara M.
      • Higashimori A.
      • Yokoi Y.
      • Honda Y.
      • Fitzgerald P.J.
      Predictors of adverse clinical outcomes after successful infrapopliteal intervention.
      reported that post-procedural pedal arch classification was an independent predictor of wound healing, whereas angiosome based direct revascularisation had no impact on wound healing. Similarly, in patients treated by infrapopliteal bypass, Rashid et al.
      • Rashid H.
      • Slim H.
      • Zayed H.
      • Huang D.Y.
      • Wilkins C.J.
      • Evans D.R.
      • et al.
      The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome.
      found that the rates of wound healing and time to healing were directly influenced by the quality of the pedal arch rather than the angiosome chosen for revascularisation. In addition, Higashimori et al.
      • Higashimori A.
      • Iida O.
      • Yamauchi Y.
      • Kawasaki D.
      • Nakamura M.
      • Soga Y.
      • et al.
      Outcomes of one straight-line flow with and without pedal arch in patients with critical limb ischemia.
       demonstrated that direct flow into a patent pedal arch is essential for improving amputation free survival and limb salvage rates, especially when only one runoff vessel can be established to the foot. Recently, Nakama et al.
      • Nakama T.
      • Watanabe N.
      • Haraguchi T.
      • Sakamoto H.
      • Kamoi D.
      • Tsubakimoto Y.
      • et al.
      Clinical outcomes of pedal artery angioplasty for patients with ischemic wounds: results from the multicenter RENDEZVOUS registry.
      reported the benefit of pedal artery angioplasty for improving wound healing in the Rendezvous prospective registry. However, the benefit was noted only in a moderate risk population, not in low or high risk patients. They defined high risk as the presence of three risk factors: (i) delayed wound healing, including non-ambulatory status; (ii) treatment by haemodialysis; and (iii) University of Texas grade ≥ 2 wound. This finding could not be confirmed in the present study population because other factors were identified as being independently associated with wound healing (gangrene, CRP > 3 mg/L, baseline pedal arch type 3, and partial or complete PAR). In previous studies, factors such as diabetes mellitus, wound infection, low serum albumin, Rutherford category 6, indirect angiosome revascularisation, and wound depth had been independently associated with wound healing.
      • Kawarada O.
      • Fujihara M.
      • Higashimori A.
      • Yokoi Y.
      • Honda Y.
      • Fitzgerald P.J.
      Predictors of adverse clinical outcomes after successful infrapopliteal intervention.
      • Shiraki T.
      • Iida O.
      • Takahara M.
      • Soga Y.
      • Yamauchi Y.
      • Hirano K.
      • et al.
      Predictors of delayed wound healing after endovascular therapy of isolated infrapopliteal lesions underlying critical limb ischemia in patients with high prevalence of diabetes mellitus and hemodialysis.
      • Kobayashi N.
      • Hirano K.
      • Nakano M.
      • Ito Y.
      • Ishimori H.
      • Yamawaki M.
      • et al.
      Clinical effect of wound depth in critical limb ischemia with tissue loss after endovascular treatment.
      There may be concerns about potential damage causing loss of target vessels for bypass with interventions on pedal arteries. However, in the present study, only one patient with a failed PAR procedure required bypass surgery. The major amputation rate in the PAR group was very low (3.9% at one year). In the present study population, the PAR success rate was relatively low (approximately 60%). However, direct angiosome flow was obtained in 81.6% of the PAR group. In the Rendezvous registry, direct revascularisation was also achieved in only 74.3% of the patients undergoing pedal artery intervention.
      • Nakama T.
      • Watanabe N.
      • Haraguchi T.
      • Sakamoto H.
      • Kamoi D.
      • Tsubakimoto Y.
      • et al.
      Clinical outcomes of pedal artery angioplasty for patients with ischemic wounds: results from the multicenter RENDEZVOUS registry.
      This may reflect the technical difficulty of the PAR in the patient with CLI due to lesion complexities. Currently, there is no guideline recommendation regarding endovascular revascularisation for inframalleolar lesions.
      • Higashimori A.
      • Iida O.
      • Yamauchi Y.
      • Kawasaki D.
      • Nakamura M.
      • Soga Y.
      • et al.
      Outcomes of one straight-line flow with and without pedal arch in patients with critical limb ischemia.
      The present study showed the benefit of pedal artery revascularisation for wound healing and may serve as clinical data supporting endovascular inframalleolar revascularisation in patients with CLI.
      Other studies have advocated the benefit of the multiple vessel revascularisation instead of single angiosome related artery revascularisation for better wound healing and limb salvage.
      • Biagioni R.B.
      • Biagioni L.C.
      • Nasser F.
      • Burihan M.C.
      • Ingrund J.C.
      • Neser A.
      • et al.
      Infrapopliteal angioplasty of one or more than one artery for critical limb ischaemia: a randomised clinical trial.
      • Ambler G.K.
      • Stimpson A.L.
      • Wardle B.G.
      • Bosanquet D.C.
      • Hanif U.K.
      • Germain S.
      • et al.
      Infrapopliteal angioplasty using a combined angiosomal reperfusion strategy.
      • Kobayashi N.
      • Hirano K.
      • Yamawaki M.
      • Araki M.
      • Takimura H.
      • Sakamoto Y.
      • et al.
      Clinical effects of single or double tibial artery revascularization in critical limb ischemia patients with tissue loss.
      However, there has been only one small prospective study.
      • Biagioni R.B.
      • Biagioni L.C.
      • Nasser F.
      • Burihan M.C.
      • Ingrund J.C.
      • Neser A.
      • et al.
      Infrapopliteal angioplasty of one or more than one artery for critical limb ischaemia: a randomised clinical trial.
      It was also thought that multivessel recanalisation would be more advantageous for wound healing than single vessel revascularisation. In particular, in patients with ischaemic wounds, an attempt was made to revascularise as many tibial and pedal arteries as possible, whenever feasible. However, the current study has shown that multivessel revascularisation was not associated with improved wound healing. Similarly, in the Rendezvous registry, multivessel infrapopliteal revascularisation had no significant impact on wound healing. Depending on various clinical and anatomical factors, such as wound extent, presence of infection, and existing perfusion status, there may be need for multivessel revascularisation. Which patient subgroups would benefit from multivessel revascularisation remains to be defined.
      This study has several limitations. Firstly, it was a single centre retrospective study, with the intrinsic limitations of this study design. Secondly, owing to the significant difference in baseline characteristics between the patient groups, only 72.8% of the study subjects could be paired for comparison. Thirdly, tissue perfusion was not evaluated before or after the procedure. Thus, the real impact of the revascularisation procedure on the perfusion of the wound area was not validated. Fourth, the treated vessels were not followed with imaging studies to directly assess the durability of the achieved patency. To validate the present findings, larger scale prospective clinical trials using objective tissue perfusion assessments are required.

      Conclusion

      Successful PAR achieved better wound healing and a higher rate of freedom from major amputation. Gangrene, high CRP, absence of a pedal arch, and successful PAR were factors independently associated with wound healing in patients undergoing endovascular therapy for CLI. Thus, efforts should be made to revascularise the pedal arteries, especially when the pedal arch is completely absent.

      Conflicts of interest

      None.

      Funding

      This study was supported by grants from the Korea Healthcare Technology Research & Development Project, Ministry for Health & Welfare, Republic of Korea (Nos. A085136 and HI15C1277 ), the Mid-Career Researcher Program through an NRF grant funded by the MEST , Republic of Korea (No. 2015R1A2A2A01002731 ), and the Cardiovascular Research Centre , Seoul, Korea.

      References

        • Shishehbor M.H.
        • White C.J.
        • Gray B.H.
        • Menard M.T.
        • Lookstein R.
        • Rosenfield K.
        • et al.
        Critical limb ischemia: an expert statement.
        J Am Coll Cardiol. 2016; 68: 2002-2015
        • Alexandrescu V.A.
        • Hubermont G.
        • Philips Y.
        • Guillaumie B.
        • Ngongang C.
        • Vandenbossche P.
        • et al.
        Selective primary angioplasty following an angiosome model of reperfusion in the treatment of Wagner 1-4 diabetic foot lesions: practice in a multidisciplinary diabetic limb service.
        J Endovasc Ther. 2008; 15: 580-593
        • Iida O.
        • Soga Y.
        • Hirano K.
        • Kawasaki D.
        • Suzuki K.
        • Miyashita Y.
        • et al.
        Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions.
        J Vasc Surg. 2012; 55: 363-370
        • Bosanquet D.C.
        • Glasbey J.C.
        • Williams I.M.
        • Twine C.P.
        Systematic review and meta-analysis of direct versus indirect angiosomal revascularisation of infrapopliteal arteries.
        Eur J Vasc Endovasc Surg. 2014; 48: 88-97
        • Sumpio B.E.
        • Forsythe R.O.
        • Ziegler K.R.
        • van Baal J.G.
        • Lepantalo M.J.
        • Hinchliffe R.J.
        Clinical implications of the angiosome model in peripheral vascular disease.
        J Vasc Surg. 2013; 58: 814-826
        • Bunte M.C.
        • Shishehbor M.H.
        Angiosome-guided intervention in critical limb ischemia.
        Interv Cardiol Clin. 2017; 6: 271-277
        • Biagioni R.B.
        • Biagioni L.C.
        • Nasser F.
        • Burihan M.C.
        • Ingrund J.C.
        • Neser A.
        • et al.
        Infrapopliteal angioplasty of one or more than one artery for critical limb ischaemia: a randomised clinical trial.
        Eur J Vasc Endovasc Surg. 2018; 55: 518-527
        • Ambler G.K.
        • Stimpson A.L.
        • Wardle B.G.
        • Bosanquet D.C.
        • Hanif U.K.
        • Germain S.
        • et al.
        Infrapopliteal angioplasty using a combined angiosomal reperfusion strategy.
        PLoS One. 2017; 12e0172023
        • Kobayashi N.
        • Hirano K.
        • Yamawaki M.
        • Araki M.
        • Takimura H.
        • Sakamoto Y.
        • et al.
        Clinical effects of single or double tibial artery revascularization in critical limb ischemia patients with tissue loss.
        J Vasc Surg. 2017; 65: 744-753
        • Kawarada O.
        • Fujihara M.
        • Higashimori A.
        • Yokoi Y.
        • Honda Y.
        • Fitzgerald P.J.
        Predictors of adverse clinical outcomes after successful infrapopliteal intervention.
        Catheter Cardiovasc Interv. 2012; 80: 861-871
        • Rashid H.
        • Slim H.
        • Zayed H.
        • Huang D.Y.
        • Wilkins C.J.
        • Evans D.R.
        • et al.
        The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome.
        J Vasc Surg. 2013; 57: 1219-1226
        • Troisi N.
        • Turini F.
        • Chisci E.
        • Ercolini L.
        • Frosini P.
        • Lombardi R.
        • et al.
        Pedal arch patency and not direct-angiosome revascularization predicts outcomes of endovascular interventions in diabetic patients with critical limb ischemia.
        Int Angiol. 2017; 36: 438-444
        • Fusaro M.
        • Dalla Paola L.
        • Biondi-Zoccai G.
        Pedal-plantar loop technique for a challenging below-the-knee chronic total occlusion: a novel approach to percutaneous revascularization in critical lower limb ischemia.
        J Invasive Cardiol. 2007; 19: E34-E37
        • Fusaro M.
        • Agostoni P.
        • Biondi-Zoccai G.
        Trans-collateral" angioplasty for a challenging chronic total occlusion of the tibial vessels: a novel approach to percutaneous revascularization in critical lower limb ischemia.
        Catheter Cardiovasc Interv. 2008; 71: 268-272
        • Patel M.R.
        • Conte M.S.
        • Cutlip D.E.
        • Dib N.
        • Geraghty P.
        • Gray W.
        • et al.
        Evaluation and treatment of patients with lower extremity peripheral artery disease: consensus definitions from Peripheral Academic Research Consortium (PARC).
        J Am Coll Cardiol. 2015; 65: 931-941
        • Mills Sr., J.L.
        • Conte M.S.
        • Armstrong D.G.
        • Pomposelli F.B.
        • Schanzer A.
        • Sidawy A.N.
        • et al.
        The society for vascular surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI).
        J Vasc Surg. 2014; 59: 220-234
        • Graziani L.
        • Silvestro A.
        • Bertone V.
        • Manara E.
        • Andreini R.
        • Sigala A.
        • et al.
        Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity.
        Eur J Vasc Endovasc Surg. 2007; 33: 453-460
        • Ko Y.G.
        • Ahn C.M.
        • Min P.K.
        • Lee J.H.
        • Yoon C.H.
        • Yu C.W.
        • et al.
        Baseline characteristics of a retrospective patient cohort in the Korean vascular intervention society endovascular therapy in lower limb artery diseases (K-VIS ELLA) registry.
        Korean Circ J. 2017; 47: 469-476
        • Adam D.J.
        • Beard J.D.
        • Cleveland T.
        • Bell J.
        • Bradbury A.W.
        • Forbes J.F.
        • et al.
        Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial.
        Lancet. 2005; 366: 1925-1934
        • Schamp K.B.
        • Meerwaldt R.
        • Reijnen M.M.
        • Geelkerken R.H.
        • Zeebregts C.J.
        The ongoing battle between infrapopliteal angioplasty and bypass surgery for critical limb ischemia.
        Ann Vasc Surg. 2012; 26: 1145-1153
        • Attinger C.E.
        • Evans K.K.
        • Bulan E.
        • Blume P.
        • Cooper P.
        Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization.
        Plast Reconstr Surg. 2006; 117: 261S-293S
        • Taylor G.I.
        • Palmer J.H.
        The vascular territories (angiosomes) of the body: experimental study and clinical applications.
        Br J Plast Surg. 1987; 40: 113-141
        • Azuma N.
        • Uchida H.
        • Kokubo T.
        • Koya A.
        • Akasaka N.
        • Sasajima T.
        Factors influencing wound healing of critical ischaemic foot after bypass surgery: is the angiosome important in selecting bypass target artery?.
        Eur J Vasc Endovasc Surg. 2012; 43: 322-328
        • Nakama T.
        • Watanabe N.
        • Haraguchi T.
        • Sakamoto H.
        • Kamoi D.
        • Tsubakimoto Y.
        • et al.
        Clinical outcomes of pedal artery angioplasty for patients with ischemic wounds: results from the multicenter RENDEZVOUS registry.
        JACC Cardiovasc Interv. 2017; 10: 79-90
        • Acin F.
        • Varela C.
        • Lopez de Maturana I.
        • de Haro J.
        • Bleda S.
        • Rodriguez-Padilla J.
        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.
        Int J Vasc Med. 2014; 2014: 270539
        • Spillerova K.
        • Biancari F.
        • Settembre N.
        • Alback A.
        • Venermo M.
        The prognostic significance of different definitions for angiosome-targeted lower limb revascularization.
        Ann Vasc Surg. 2017; 40: 183-189
        • Rother U.
        • Krenz K.
        • Lang W.
        • Horch R.E.
        • Schmid A.
        • Heinz M.
        • et al.
        Immediate changes of angiosome perfusion during tibial angioplasty.
        J Vasc Surg. 2017; 65: 422-430
        • Higashimori A.
        • Iida O.
        • Yamauchi Y.
        • Kawasaki D.
        • Nakamura M.
        • Soga Y.
        • et al.
        Outcomes of one straight-line flow with and without pedal arch in patients with critical limb ischemia.
        Catheter Cardiovasc Interv. 2016; 87: 129-133
        • Shiraki T.
        • Iida O.
        • Takahara M.
        • Soga Y.
        • Yamauchi Y.
        • Hirano K.
        • et al.
        Predictors of delayed wound healing after endovascular therapy of isolated infrapopliteal lesions underlying critical limb ischemia in patients with high prevalence of diabetes mellitus and hemodialysis.
        Eur J Vasc Endovasc Surg. 2015; 49: 565-573
        • Kobayashi N.
        • Hirano K.
        • Nakano M.
        • Ito Y.
        • Ishimori H.
        • Yamawaki M.
        • et al.
        Clinical effect of wound depth in critical limb ischemia with tissue loss after endovascular treatment.
        J Vasc Surg. 2015; 62: 1564-1574

      Linked Article

      • Pedal Artery Revascularisation: ‘Bogey’, ‘Birdie’, or ‘Eagle’ in the Treatment of Chronic Limb Threatening Ischaemia?
        European Journal of Vascular and Endovascular SurgeryVol. 58Issue 6
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          In this issue of the European Journal of Vascular and Endovascular Surgery, Jung et al. describe their experience with pedal artery revascularisation (PAR) and more importantly the mid term outcomes with respect to wound healing and major amputation rates.1 More than a decade ago PAR was described as feasible,2 but the influence on outcome is less well established and therefore the benefit of PAR remains controversial. This paper tries to put in place another piece of the complex puzzle that is the treatment of chronic limb threatening ischaemia (CLTI).
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