title: The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome.
abstract: OBJECTIVE
  This study evaluated the effect of pedal arch quality on the amputation-free survival and patency rates of distal bypass grafts and its direct impact on the rate of healing and time to healing of tissue loss after direct angiosome revascularization in patients with critical limb ischemia (CLI).
  
  
  METHODS
  Between 2004 and 2011, patients undergoing distal bypass for CLI (Rutherford 4-6) were divided in groups taking into consideration the state of the pedal arch and direct angiosome revascularization (DAR) and non-DAR. Angiography was used to divide the pedal arch into three groups: complete pedal arch (CPA), incomplete pedal arch (IPA), and no pedal arch (NPA). The primary end points were patency rates at 12 months, amputation-free survival at 48 months, and the rate of healing and time to healing of foot tissue loss.
  
  
  RESULTS
  A total of 154 patients (75% men) with CLI underwent 167 infrapopliteal bypasses. Patients were a median age of 75 years (range, 46-96 years). Diabetic mellitus was present in 76%, chronic renal failure in 28%, and ischemic heart disease in 44%. The primary patency rates at 1 year in the CPA, IPA, and NPA groups were 58.4%, 54.6%, and 63.8%, respectively (P = .5168), the secondary patency rates were 86.0%, 84.7%, and 88.8%, respectively (P = .8940), and the amputation-free survival at 48 months was 67.2%, 69.7%, and 45.9%, respectively (P = .3883). Tissue loss was present in 141 of the 167 bypasses. In the CPA group, 83% of tissue loss with DAR healed compared with 92% in the non-DAR (median time to healing, 66 vs 74 days). Similarly in the IPA group, 90% with DAR healed compared with 81% in the non-DAR (median time to healing, 96 vs 86 days). In the NPA group, only 75% with DAR healed compared with 73% in the non-DAR (median time to healing, 90 vs 135 days). There was a significant difference in healing and time to healing between the CPA/IPA and NPA groups (P = .0264).
  
  
  CONCLUSIONS
  The quality of the pedal arch did not influence the patency or the amputation-free survival rates. However, the rates for healing and time to healing were directly influenced by the quality of the pedal arch rather than the angiosome revascularized.
authors.affiliation: King's Health Partners Vascular Unit at King's College, Guy's and St Thomas' Hospitals, London, United Kingdom. hisham.rashid@nhs.net
authors.forename: Hisham
authors.initials: H
authors.lastname: Rashid
authors.forename: Hani
authors.initials: H
authors.lastname: Slim
authors.forename: Hany
authors.initials: H
authors.lastname: Zayed
authors.forename: Dean Y
authors.initials: DY
authors.lastname: Huang
authors.forename: C Jason
authors.initials: CJ
authors.lastname: Wilkins
authors.forename: David R
authors.initials: DR
authors.lastname: Evans
authors.forename: Paul S
authors.initials: PS
authors.lastname: Sidhu
authors.forename: Michael
authors.initials: M
authors.lastname: Edmonds
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D015901:Angiography, Digital Subtraction; D016638:Critical Illness; D018572:Disease-Free Survival; D005260:Female; D005528:Foot / Q000098:blood supply*; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012039:Regional Blood Flow; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D058017:Vascular Grafting / Q000009:adverse effects; D014654:Vascular Patency; D014945:Wound Healing