title: Angiosome Targeted PTA is More Important in Endovascular Revascularisation than in Surgical Revascularisation: Analysis of 545 Patients with Ischaemic Tissue Lesions.
abstract: BACKGROUND
  This study aimed to evaluate the impact of angiosome targeted (direct) revascularisation according to revascularisation method in patients with diabetes.
  
  
  METHODS
  This retrospective study cohort comprised 545 diabetic patients with critical limb ischaemia and tissue loss (Rutherford 5, 6). All patients underwent infrapopliteal endovascular (PTA) or open surgical revascularisation between January 2008 and December 2013. Differences in the outcome after direct revascularisation, bypass surgery, and PTA were investigated by means of Cox proportional hazards analysis. The endpoints were wound healing, leg salvage, and amputation free survival.
  
  
  RESULTS
  Overall, 60.3% of the ischaemic wounds healed during 1 year of follow-up. The highest wound healing rate was achieved after direct bypass (77%) and the worst after indirect PTA (52%). The Cox proportional hazards analysis showed that the number of affected angiosomes <3 (HR 1.37, 95% CI 1.01-1.84) was associated with improved wound healing, whereas wound healing was poorest after indirect PTA (p = .001). When Cox proportional hazard analysis was adjusted for the number of affected angiosomes, direct bypass gave the best wound healing (p = 0.003). The overall amputation rate was 25.1% at 1 year of follow-up, and the Cox proportional hazards analysis indicated that haemodialysis compared with patients with no haemodialysis (HR 2.55, 95% CI 1.49-4.38), C-reactive protein ≥10 mg/dL (HR 2.05, 95% CI 1.45-2.90), atrial fibrillation (HR 1.54, 95% CI 1.05-2.26), and number of affected angiosomes >3 (HR 1.75, 95% CI 1.24-2.46) were significantly associated with poor leg salvage. Direct PTA was associated with a lower rate of major amputation compared with indirect PTA (HR 0.57 95% CI 0.37-0.89).
  
  
  CONCLUSIONS
  In diabetics, indirect endovascular revascularisation leads to significantly worse wound healing and leg salvage rates compared with direct revascularisation. Therefore, endovascular procedures should be targeted according to the angiosome concept. In bypass surgery, however, the concept is of less value and the artery with the best runoff should be selected as the outflow artery.
authors.affiliation: University of Helsinki, Helsinki University Hospital, Department of Vascular Surgery, Helsinki, Finland. Electronic address: kspillerova@gmail.com.
authors.forename: K
authors.initials: K
authors.lastname: Špillerová
authors.affiliation: University of Helsinki, Helsinki University Hospital, Department of Vascular Surgery, Helsinki, Finland.
authors.forename: N
authors.initials: N
authors.lastname: Settembre
authors.affiliation: Oulu University Hospital, Department of Surgery, Oulu, Finland.
authors.forename: F
authors.initials: F
authors.lastname: Biancari
authors.affiliation: University of Helsinki, Helsinki University Hospital, Department of Vascular Surgery, Helsinki, Finland.
authors.forename: A
authors.initials: A
authors.lastname: Albäck
authors.affiliation: University of Helsinki, Helsinki University Hospital, Department of Vascular Surgery, Helsinki, Finland.
authors.forename: M
authors.initials: M
authors.lastname: Venermo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D000800:Angioplasty, Balloon / Q000009:adverse effects; D003097:Collateral Circulation; D016638:Critical Illness; D003925:Diabetic Angiopathies / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D008955:Models, Cardiovascular; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D016016:Proportional Hazards Models; D012039:Regional Blood Flow; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects; D014945:Wound Healing
keywords: Angiosome; Diabetes mellitus; Infrapopliteal revascularization; Wound