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Angiosomal Revascularisation May Be More Fiction than Fact

Open ArchivePublished:March 27, 2020DOI:https://doi.org/10.1016/j.ejvs.2020.03.001
      Whether or not to use the angiosome theory as a guide for revascularisation in patients with chronic limb threatening ischaemia (CLTI) has been discussed for more than a decade and still remains controversial. The literature consists of mainly retrospective case reports with one small prospective series as the only exception. No randomised controlled trials (RCTs) have been published so we cannot generate level one data to support decision making.
      Hart et al. present yet another retrospective case series on the results of femorodistal bypass surgery using either direct (DR) or indirect revascularisation (IR).
      • Hart C.
      • Randon C.
      • Vermassen F.
      Impact of angiosome targeted femorodistal bypass surgery on healing rate and outcome in chronic limb threatening ischaemia.
      This report appears to be the largest series published regarding the results from bypass surgery, showing little or no difference in wound healing or limb salvage between DR and IR. These results seem to agree with the results of a recently published meta-analysis,
      • Dilaver N.
      • Twins C.P.
      • Bosanquet D.C.
      Editor's Choice – direct vs. indirect angiosomal revascularisation of infrapopliteal arteries, an updated systematic review and meta-analysis.
      in contrast to results reported earlier for endovascular revascularisations where DR seems to give better results than IR.
      There are lots of biases in retrospective case series but still one can speculate on the reasons for the observed differences in outcomes for endovascular treatment and open bypass surgery. Our methods of looking at the macrocirculation are usually not as detailed when it comes to assessing the microcirculation. There are obviously collateral circulation pathways that are not always observed on traditional angiograms of various sorts. One reason for the better results from IR using bypass techniques could be the ability of vein bypasses to function also with low blood flow velocities that could be caused by collaterals between angiosomes. This also possibly could explain the poorer results from IR using endovascular techniques, in which high flow is usually necessary to keep the reconstructions open.
      In Hart et al.’s report, autologous vein appeared to perform best but surprisingly good results were also reported for cryopreserved saphenous veins that accounted for around half of all bypasses. The latter option has not been used widely and today it may be even more difficult to get these grafts. Hart et al. recruited patients over a 20 year period and all received anticoagulation with warfarin, a secondary preventive measure not generally used after vein bypass surgery. The majority of the patients were operated on before statin use became standard treatment for peripheral arterial disease, but whether and in what way wider use of statins would alter results regarding angiosome revascularisation is not known. One important question following what has been published regarding the angiosome theory is how to interpret the published results? It is not likely that we will ever have results from randomised studies to support our decisions in this matter, because of the complexity and the individual variations regarding CLTI, diagnostics, and treatment modalities. We need to come to some conclusions based on available, and admittingly very weak, evidence.
      Hart et al. detected no major outcome differences for vein bypass surgery whether DR or IR was used, which supports results from the most recent review.
      • Dilaver N.
      • Twins C.P.
      • Bosanquet D.C.
      Editor's Choice – direct vs. indirect angiosomal revascularisation of infrapopliteal arteries, an updated systematic review and meta-analysis.
      Based on that review it was shown that endovascular revascularisation worked better for DR than for IR. I would suggest, based on these available results, that you could always go for a vein bypass regardless of whether that will result in DR or IR. If DR is possible you could probably try endovascular methods, but avoid these if IR is necessary and choose, if possible, a vein bypass instead. The statement in the ESC Guidelines that you should not use the angiosome model as an absolute guide for revascularisation seems sensible.
      • Aboyans V.
      • Ricco J.B.
      • Bartelink M.E.L.
      • Bjorck M.
      • Brodmann M.
      • Cohnert T.
      • et al.
      Editor's Choice – 2017 ESC Guidelines on the diagnosis and treatment of peripheral arterial disease, in collaboration with the European Society for Vascular Surgery (ESVS).
      There is no need for more retrospective data regarding angiosomal revascularisation, we seem to have enough by now.

      References

        • Hart C.
        • Randon C.
        • Vermassen F.
        Impact of angiosome targeted femorodistal bypass surgery on healing rate and outcome in chronic limb threatening ischaemia.
        Eur J Vasc Endovasc Surg. 2020; 60: 68-75
        • Dilaver N.
        • Twins C.P.
        • Bosanquet D.C.
        Editor's Choice – direct vs. indirect angiosomal revascularisation of infrapopliteal arteries, an updated systematic review and meta-analysis.
        Eur J Vasc Endovasc Surg. 2018; 56: 834-848
        • Aboyans V.
        • Ricco J.B.
        • Bartelink M.E.L.
        • Bjorck M.
        • Brodmann M.
        • Cohnert T.
        • et al.
        Editor's Choice – 2017 ESC Guidelines on the diagnosis and treatment of peripheral arterial disease, in collaboration with the European Society for Vascular Surgery (ESVS).
        Eur J Vasc Endovasc Surg. 2018; 55: 305-368

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