title: Long-term outcomes of direct and indirect below-the-knee open revascularization based on the angiosome concept in diabetic patients with critical limb ischemia.
abstract: BACKGROUND
  We compared long-term outcomes of isolated below-the-knee (BTK) bypass revascularization in diabetic patients presenting with critical limb ischemia (CLI) with and without achieving the bypass on the artery corresponding to the territory of the lesion based on the angiosome concept.
  
  
  METHODS
  We analyzed outcomes of 58 consecutive CLI limbs of 54 diabetic patients presenting with tissue loss who underwent isolated BTK bypasses from 2003 to 2009 for crural occlusive arterial disease. Bypasses were classified into direct and indirect groups based on the angiosome concept, whether feeding artery flow to the site of ischemic tissue loss was achieved or not. We compared median ulcer-healing time, survival, primary patency, and limb salvage rates between both groups by Kaplan-Meier analysis and log-rank test. Independent factors of major amputations were explored by univariate analysis. Variables with P < 0.2 in univariate analysis were submitted to multivariable analysis.
  
  
  RESULTS
  Median ulcer-healing time was 56 ± 18 days in direct group (n = 36) and 112 ± 45 days in indirect group (n = 22, P = 0.01). There was no difference between both groups in terms of survival or primary patency. Limb salvage rate was significantly higher in direct group than in indirect group: 91% vs. 66% at 1 year, 65% vs. 24% at 3 years, and 58% vs. 18% at 5 years, respectively (P = 0.03). After multivariable Cox proportional analysis, independent factors associated with major amputation were end-stage renal disease (P = 0.030) and C-reactive protein level (P = 0.025).
  
  
  CONCLUSIONS
  Achieving a direct arterial flow based on angiosome concept in CLI diabetic patients presenting with tissue loss appears to be important for ulcer healing and limb salvage.
authors: Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France. Electronic address: anne.lejay@chru-strasbourg.fr.
authors: Anne
authors: A
authors: Lejay
authors: Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France.
authors: Yannick
authors: Y
authors: Georg
authors: Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France.
authors: Elvira
authors: E
authors: Tartaglia
authors: Department of Hypertension and Vascular Diseases, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France.
authors: Sébastien
authors: S
authors: Gaertner
authors: Department of Physiology, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France.
authors: Bernard
authors: B
authors: Geny
authors: Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France.
authors: Fabien
authors: F
authors: Thaveau
authors: Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France.
authors: Nabil
authors: N
authors: Chakfe
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D016638:Critical Illness; D017719:Diabetic Foot / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D008953:Models, Anatomic; D008955:Models, Cardiovascular; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D016016:Proportional Hazards Models; D012039:Regional Blood Flow; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects; D014945:Wound Healing