The impact of angiosome-specific infrapopliteal bypass revascularization and arterial pedal arch patency on wound healing
Louis Zhang, MD, Gregory Magee, MD, Jack Yi, MD, Sung Ham, MD, Vincent Rowe, MD, Kenneth Ziegler, MD, Fred Weaver, MD.
Keck School of Medicine USC, Los Angeles, CA, USA.
OBJECTIVES: The aim of this study was to evaluate the effect of angiosome-specific revascularization on wound healing and amputation-free survival following infrapopiteal bypass (IPB) for tissue loss. The impact of pedal arch patency directly on tissue loss wound healing was also evaluated.
METHODS: Our single-center Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) registry was queried to identify IPB procedures in the setting of (critical limb-threatening ischemia) CLTI with tissue loss between 2010-2018. Screening was then performed to identify patients with pedal arch angiograms and those with outcomes of either complete wound healing or requiring amputation. We examined for variables associated with pedal arch patency and the ability to perform direct (DR) or indirect (IR) angiosome revascularization or mixed for complex wounds. Pedal arch patency was defined as either incomplete/no pedal arch (IPA), collateraized pedal arch (CPA), or fully patent pedal arch (FPA).
RESULTS: 51 consecutive IPB procedures with complete pedal angiograms and follow-up were identified from screening 113 total patients who underwent IPB for CLTI with tissue loss from our VQI database. Direct angiosome revascularization resulted in 88.9% wound healing while indirect revascularization resulted in 58.8% wound healing (P = 0.190). 50% of patients who had wounds encompassing mixed angiosomes were able to heal after bypass (P = 0.371). Average time to heal for DR, IR, or mixed angiosome revascularization were 260 days, 181 days, and 166 days, respectively. One amputation occurred in each angiosome group after initial wounds healed. Pedal arch patency was associated with wound healing. In the FPA group, 100% healed their wounds (n = 9), while CPA and IPA groups had wound healing rates of 37.5% (n = 8) and 67.3% (n = 34), respectively (P = 0.017). FPA, CPA, and IPA were observed in 7.9%, 15.7%, and 75%, respectively, in diabetic patients (n = 38). Diabetes mellitus was strongly associated with a compromised pedal arch (P = 0.007) though not with whether direct or indirect revascularization could be performed (P = 0.098).
CONCLUSIONS: The degree of pedal arch patency was significantly associated with wound healing and inversely associated with diabetes mellitus. Assessments of causation will require a larger study population. Direct angiosome revascularization did not significantly increase wound healing compared to indirect revascularization in our sample.
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