ANGIOSOMAS MITO O REALIDAD copia.key

CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
DR LUIS RICARDO SANCHEZ ESCALANTE
MONTERREY, NUEVO LEON, MEXICO
somes have been additionally considered by recent reports of
revascularization procedures.15,16,18 A few examples of current
angiosome-guided endovascular interventions for diabetic
neuroischemic foot wounds are shown in Figures 2–9.
The diabetic foot is a preferential application for topographic revascularization. Availability of the angiosome strategy for infragenicular revascularization seems to represent
millimeters of skin to the entire diabetic foot or leg11,16,17,21
relies on specific nourishing vessels, although solely hinged
to one specific dominant angiosome-dependent artery.9–12
Consequently, it might be emphasized that in these subjects,
the more distal and specific the revascularization, the higher
the probability of re-establishing an adequate blood supply
in a specific amount of threatened tissue.
PRIMERAS PUBLICACIONES TAYLOR
Figure 1 A simplified illustration of previously suggested angiosomes of the foot and lower ankle.
Abbreviations: DP, dorsalis pedis artery angiosome; LP, lateral plantar artery angiosome; MP, medial plantar artery angiosome; LC, lateral calcaneal artery angiosome;
MC, medial calcaneal artery angiosome.
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
•
•
•
PRIMERA DESCRIPCION POR JAN TAYLOR 1987
EL OBJETIVO ES DEFINIR LA ARTERIA DEL AREA
EL TEMA ES ES APLICABLE UNIVERSALMENTE?
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
CLI
Wound Healing
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
• Healing a
– Non linea
• Probabili
– Suboptim
– Maximize
and perfu
– Best pres
durable p
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
!"#$%&'()*$+,-''(.(/-0()*
1%
8%
14%
36%
~ 50% long occlusions (>10cm)
11%
27%
1%
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
•
EL FLUJO COMPARTAMENTADO EN EL PIE
DIABETICO IMPIDE LA ADECUADA PERFUSION DEL
PIE ISQUEMICO
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
ESTUDIOS CLINICOS
procedimiento
rev directa rev indirecta
ATTINGER
52 bypass
distal
81%
62%
LIDA et al
203 endov
86%
69%
92%
73%
VARELA et
76 endo y qx
al
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
AMPUTACION O FRACASO CLÍNICO A PESAR DE BY-PASS
PERMEABLE!
ESTUDIO!
Goodney et al!
PACIENTES CON CLI!
2306 bypass!
8% amputaciones en un
año, 17% de ellas con
bypass permeable!
1012 bypass!
10% de los pacientes con
bypass permeable sin
mejoría clínica!
361 bypass!
316 PTA!
Permeabilidad, sobrevida,
salvamento de extremidad y
deambulación a un año:
37% para ATP y 44% para
bypass!
Ann Vasc Surg 2010; 24:59!
Simons et al!
J Vasc Surg 2010;51:1419!
Taylor et al!
J Vasc Surg 2009;50:534!
RESULTADOS!
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
NO HAY DUDA QUE UNA ARTERIA CON PULSO ES
NUESTRO OBJETIVO
•
EL ESTUDIO ORIGINAL DE TAYLOR FUE EN
ARTERIAS NO ATEROESCLEROTICAS
•
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
LIMITACIONES
!
NO EXISTE UNA ESTRATIFICACION UNIFORME PARA
LA SELECCION DEL PACIENTE, TIPO DE
PROCEDIMIENTO
EL CONCEPTO IMPLICA QUE EL SITIO DE LA LESION
NOS INDICA LA ARTERIA A TRATAR
SIN EMPARGO EL PAC DIABETICO SE PRESENTA CON
LESIONES HETEROGENEAS DIFUSAS, QUE INCLUSO
PUEDEN INVOLUCRAR DOS ANGIOSOMAS Y
PRODUCIR AMBIGUEDAD
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
Hindawi Publishing Corporation
International Journal of Vascular Medicine
Volume 2014, Article ID 672897, 6 pages
Hindawi Publishing Corporation
http://dx.doi.org/10.1155/2014/672897
International Journal of Vascular Medicine
Volume 2014, Article ID 672897, 6 pages
http://dx.doi.org/10.1155/2014/672897
Clinical Study
Wound Morphology and Topography in the Diabetic Foot:
Clinical Study
Hurdles in Implementing
Angiosome-Guided
Revascularization
Wound Morphology
and Topography
in the Diabetic Foot:
Hurdles in Implementing Angiosome-Guided Revascularization
2
Dimitri Aerden,1,2 Nathalie Denecker,1 Sarah Gallala,2
Erik Debing,2 and Pierre Van den Brande2
1,2
International Journal of Vascular Medicine
Dimitri Aerden,
Nathalie Denecker,1 Sarah Gallala,2
1
Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
2 Diabetic Foot Clinic, Universitair Ziekenhuis
2
Erik Debing, and
Pierre Van den Brande
2
Department of Vascular Surgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
1
Diabetic Foot Clinic,Correspondence
Universitair Ziekenhuis
Brussel,
Laarbeeklaan
1090 Jette,
Belgium
should be
addressed
to Dimitri101,
Aerden;
[email protected]
Department of Vascular Surgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
Received 11 July 2013; Revised 2 December 2013; Accepted 13 December 2013; Published 2 February 2014
Correspondence should be addressed to Dimitri Aerden; [email protected]
Academic Editor: Georgios Vourliotakis
Received 11 July 2013; Revised 2 December 2013; Accepted 13 December 2013; Published 2 February 2014
Copyright © 2014 Dimitri Aerden et al. This is an open access article distributed under the Creative Commons Attribution License,
Academic Editor: Georgios
Vourliotakis
which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2
Copyright © 2014 Dimitri Aerden et al. This is an open access article distributed under the Creative Commons Attribution License,
Purpose. Angiosome-guided revascularization is an approach that improves wound healing but requires a surgeon to determine
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
which angiosomes are ischemic. This process can be more difficult than anticipated because diabetic foot (DF) wounds vary greatly
in quantity, morphology, and topography. This paper explores to what extent the heterogeneous presentation of DF wounds impedes
Purpose. Angiosome-guided revascularization is an approach that improves wound healing but requires a surgeon to determine
development of a proper revascularization strategy. Methods. Data was retrieved from a registry of patients scheduled for belowwhich angiosomes are ischemic. This process can be more difficult than anticipated because diabetic foot (DF) wounds vary greatly
the-knee (BTK) revascularization. Photographs of the foot and historic benchmark diagrams were used to assign wounds to their
in quantity, morphology, and topography. This paper explores to what extent the heterogeneous presentation of DF wounds impedes
respective angiosomes. Results. In 185 limbs we detected 345 wounds. Toe wounds (53.9%) could not be designated to a specific
development of a proper revascularization
strategy. Methods. Data was retrieved from
of patients scheduled for below(b) a registry
angiosome due(a)to dual blood supply. Ambiguity in wound stratification
into angiosomes was highest at the heel, achilles tendon,
the-knee (BTK) revascularization. Photographs of the foot and historic benchmark diagrams were used to assign wounds to their
and lateral/medial side of the foot and lowest for malleolar wounds. In 18.4% of the DF, at least some wounds could not confidently be
respective angiosomes. Results. In 185 limbs we detected 345 wounds. Toe wounds (53.9%) could not be designated to a specific
categorized. Proximal wounds (coinciding with toe wounds) further steered revascularization strategy in 63.6%. Multiple wounds
angiosome due to dual blood supply. Ambiguity in wound stratification into angiosomes was highest at the heel, achilles tendon,
required multiple BTK revascularization in 8.6%. Conclusion. The heterogeneous presentation in diabetic foot wounds hampers
and lateral/medial side of the foot and lowest for malleolar wounds. In 18.4% of the DF, at least some wounds could not confidently be
unambiguous identification of ischemic angiosomes, and as such diminishes the capacity of the angiosome model to optimize
categorized. Proximal wounds (coinciding with toe wounds) further steered revascularization strategy in 63.6%. Multiple wounds
revascularization strategy.
required multiple BTK revascularization in 8.6%. Conclusion. The heterogeneous presentation in diabetic foot wounds hampers
unambiguous identification of ischemic angiosomes, and as such diminishes the capacity of the angiosome model to optimize
revascularization strategy.
1. Introduction
are indispensable for wound healing. In practice, however,
diabetic patients present with a multitude of wounds that are
Below-the-knee (BTK) revascularization encompassing enin morphology
andhowever,
topography. For example,
1. Introduction
are indispensable heterogeneous
for wound healing.
In practice,
dovascular angioplasty and distal bypass surgery is essential
a
patient
may
present
with
several
wounds
diabetic patients present with a multitude of wounds that
are dispersed over
for
successful
treatment
of
ischemic
diabetic
foot
ulcers
[1].
more
than
one
angiosome
or
manifest
a large ulcer that lies
Below-the-knee (BTK) revascularization encompassing enheterogeneous in morphology and topography. For example,
Angiosome-guided
revascularization
is a paradigm that has
on
the
verge
of
two
angiosomes.
Under
these circumstances,
dovascular angioplasty
and distal bypass
surgery is essential
a patient may present with several wounds dispersed over
generated
considerable
interest
suggested
determining
which
below-the-knee
artery
for successful treatment
of ischemic
diabetic
foot since
ulcersstudies
[1]. have
more than one angiosome or manifest a large ulcer that liesto target for revasdirect revascularization
of the
angiosome
may
be less
straightforward
than anticipated.
Angiosome-guidedthat
revascularization
is a paradigm
thatappropriate
has
on the verge of twocularization
angiosomes.
Under
these
circumstances,
(where
antegrade
pulsatile
flow
is
reinstated
to
the
angiosome
In this study, artery
we assessed
thefor
localization
and morpholgenerated considerable interest since studies have suggested
determining which below-the-knee
to target
revasthat harborsof the
yieldsangiosome
superior results compared
ogy
ofstraightforward
ischemic diabetic
foot
wounds. Based on the presenthat direct revascularization
the ulcer)
appropriate
(c)
(d)
cularization may be
less
than
anticipated.
to indirect
3]. On the contrary, some
tation
of these
we set
to investigate the level of
(where antegrade pulsatile
flowrevascularization
is reinstated to the[2,angiosome
In this study, we
assessed
thewounds,
localization
andout
morpholhave
that
angiosome-guided
Figure
1: Composite
imageyields
of all disputed
wounds
showing
predisposing
Likelihood to contain
woundsto
varies
fromwhich
red (most
likely) to require
blue revascularizadifficulty
identify
angiosomes
that
harbors
the authors
ulcer)
superior
results
comparedareas.revascularizaogy of ischemic diabetic foot wounds. Based on the presenlikely).revascularization
tion considerably
clinical outcome
tion.
to(least
indirect
[2, 3].improves
On the contrary,
some [4–7].
tation of these wounds, we set out to investigate the level of
revascularization
that thetodeauthors have disputedAngiosome-guided
that angiosome-guided
revasculariza-implies
difficulty
identify which angiosomes require revascularizacision of which
to target
for revascularization
tion considerably improves
clinicalartery
outcome
[4–7].
tion. is based
4
CONCEPTO DEL ANGIOSOMA
MITO O REALIDAD?
International Journal of Vascular Medicine
Toe wounds (grouped)
Table 2: Categorization of individual wounds into angiosomes (𝑛 = 345).
Toe wounds (including webspace)
169 (49.0%)
Toe amputation sites
16 (4.6%)
Forefoot amputation site
No classification into angiosome possible
(either tibial artery is elible for revascularization)
1 (0.3%)
186 (53.9%)
Classification into angiosome
Unambiguous
Ambiguous
Proximal wounds
Plantar foot (excluding the heel)
Dorsal foot
Lateral or medial side of the foot
Heel (plantar, lateral, and medial)
Ankle (malleolar)
Above the ankle
25 (7.2%)
23 (6.7%)
43 (12.5%)
23 (6.7%)
23 (6.7%)
22 (6.4%)
159 (46.1%)
345 (100.0%)
Total
19 (76.0%)
21 (91.3%)
25 (58.1%)
17 (73.9%)
23 (100.0%)
17 (77.3%)
122 (76.7%)
6 (24.0%)
2 (8.7%)
18 (41.9%)
6 (26.1%)
0 (0.0%)
5 (22.7%)
37 (23.3%)
Table 3: Wound composition in diabetic feet (𝑛 = 185).
Wound composition
Feet with toe wounds exclusively
Feet with toe wounds and proximal wounds
Wounds that could be unambiguously classified
All
Some
Revascularization strategy
85 (45.9%)
33 (17.8%)
16 (8.6%)
5 (2.7%)
85 anterior or posterior tibial artery revascularization
2 additional peroneal artery revascularisation
=21 14 additional argument for anterior tibial revascularisation
3 additional argument for posterior tibial revascularisation
CONCLUSIONES
!
EL PIE DIABETICO TIENE UNA RED COLATERAL
FORMADA POR LA ATEROESCLEROSIS
PUEDE SER AMBIGUA LA ARTERIA TARGET
ES IMPORTANTE EN LESIONES SEGMENTARIAS EN
ARTERIA Y EL PIEL
NO ES UN CONCEPTO QUE DEBAMOS DE
DESCARTAR DE NUESTRA PRACTICA
SE REQUIERE ESTABLECER EL MODELO EN PACIENTES
DIABETICOS