Experts to Debate the Angiosome Concept for Critical Limb Ischemia

Traditionally, revascularization procedures for patients with critical limb ischemia (CLI) have focused on the best quality vessel that can be visualized by angiogram, according to Dr. Cynthia Shortell of Duke University Medical Center. An alternative approach is to consider the angiosome to which the affected tissue belongs, but this strategy remains controversial, she noted. On Wednesday afternoon, Dr. Shortell will co-moderate a discussion and debate on applying the angiosome concept to CLI treatment decisions, particularly for patients with tibial disease and tissue loss.

Rates of peripheral arterial disease (PAD) are climbing worldwide, fueled by global population aging and increasing numbers of patients with diabetes mellitus and other risk factors for PAD. Critical limb ischemia, the most severe manifestation of PAD, requires prompt revascularization to prevent severe outcomes such as limb loss and death. When treating lower-limb CLI, vascular surgeons have typically targeted the anterior and posterior tibial arteries instead of the peroneal artery because of their contributions to the pedal arch, Dr. Shortell noted.

But even when conventional revascularization seems to go well, patients can experience poor outcomes such as unhealed wounds and secondary amputation. Because of this problem, some endovascular and vascular surgeons have begun applying the angiosome concept to target vessel selection. Angiosomes are 3-D units of tissue that are fed and drained by specific arteries and veins. “The angiosome concept was first used by plastic surgeons for the purpose of healing flaps, and while it has been introduced to vascular surgery, it has not been embraced widely,” Dr. Shortell said.

Vascular surgeons who use the angiosome concept argue that it can improve vessel selection and vascular access. Some researchers have reported improved ulcer healing and limb preservation after angiosome-based surgical bypass and endovascular approaches. The angiosome concept may be especially useful for vascular reconstructions in patients with renal insufficiency, diabetes, ischemic tissue lesions of the lower limb, and extensive breakdown of collateral vascular networks, according to other studies.

But other CLI experts have asserted that the angiosome concept is not ready for prime time. They have cited a lack of well-designed, prospective trials of large groups of patients, a failure to match patients adequately to compare traditional and angiosome-guided revascularization, and a dearth of data on how the severity of arterial disease affects outcomes.

To help attendees evaluate these issues, Dr. Richard Neville of George Washington University and Dr. Bauer Sumpio of the Yale School of Medicine will kick off Wednesday’s session by debating utility of the angiosome concept for open surgical and endovascular treatment of CLI with gangrenous or ulcerated lesions.
“This will be a great discussion between two experts on the merits of this approach in revascularizing patients with tibial disease and tissue loss,” Dr. Shortell said. “The angiosome concept is an important factor in decision-making around choice of target vessel to revascularize, but it’s not the only one. A good target vessel is still the most important thing, but if given the choice, revascularizing the vessel that is associated with the lesion in question optimizes the chance of wound healing and limb salvage.”

Dr. Shortell also noted that applying the angiosome concept can be more important when using an endovascular approach, which presents more options in terms of target vessels compared with the open bypass approach. “As endovascular therapy improves with drug-eluting balloons and other advanced therapies to successfully treat tibial lesions, the angiosome concept will become increasingly important,” she added. “We will have the opportunity to go the extra mile to open up the relevant vessel when given the choice.”

Session 30: CLI and the Angiosome Concept; Reoperations and Reintervention; Other New Concepts and Techniques

Wednesday, 4:39 p.m. – 5:58 p.m.

Grand Ballroom East, 3rd Floor

Traditionally, revascularization procedures for patients with critical limb ischemia (CLI) have focused on the best quality vessel that can be visualized by angiogram, according to Dr. Cynthia Shortell of Duke University Medical Center. An alternative approach is to consider the angiosome to which the affected tissue belongs, but this strategy remains controversial, she noted. On Wednesday afternoon, Dr. Shortell will co-moderate a discussion and debate on applying the angiosome concept to CLI treatment decisions, particularly for patients with tibial disease and tissue loss.

Rates of peripheral arterial disease (PAD) are climbing worldwide, fueled by global population aging and increasing numbers of patients with diabetes mellitus and other risk factors for PAD. Critical limb ischemia, the most severe manifestation of PAD, requires prompt revascularization to prevent severe outcomes such as limb loss and death. When treating lower-limb CLI, vascular surgeons have typically targeted the anterior and posterior tibial arteries instead of the peroneal artery because of their contributions to the pedal arch, Dr. Shortell noted.

But even when conventional revascularization seems to go well, patients can experience poor outcomes such as unhealed wounds and secondary amputation. Because of this problem, some endovascular and vascular surgeons have begun applying the angiosome concept to target vessel selection. Angiosomes are 3-D units of tissue that are fed and drained by specific arteries and veins. “The angiosome concept was first used by plastic surgeons for the purpose of healing flaps, and while it has been introduced to vascular surgery, it has not been embraced widely,” Dr. Shortell said.

Vascular surgeons who use the angiosome concept argue that it can improve vessel selection and vascular access. Some researchers have reported improved ulcer healing and limb preservation after angiosome-based surgical bypass and endovascular approaches. The angiosome concept may be especially useful for vascular reconstructions in patients with renal insufficiency, diabetes, ischemic tissue lesions of the lower limb, and extensive breakdown of collateral vascular networks, according to other studies.

But other CLI experts have asserted that the angiosome concept is not ready for prime time. They have cited a lack of well-designed, prospective trials of large groups of patients, a failure to match patients adequately to compare traditional and angiosome-guided revascularization, and a dearth of data on how the severity of arterial disease affects outcomes.

To help attendees evaluate these issues, Dr. Richard Neville of George Washington University and Dr. Bauer Sumpio of the Yale School of Medicine will kick off Wednesday’s session by debating utility of the angiosome concept for open surgical and endovascular treatment of CLI with gangrenous or ulcerated lesions.
“This will be a great discussion between two experts on the merits of this approach in revascularizing patients with tibial disease and tissue loss,” Dr. Shortell said. “The angiosome concept is an important factor in decision-making around choice of target vessel to revascularize, but it’s not the only one. A good target vessel is still the most important thing, but if given the choice, revascularizing the vessel that is associated with the lesion in question optimizes the chance of wound healing and limb salvage.”

Dr. Shortell also noted that applying the angiosome concept can be more important when using an endovascular approach, which presents more options in terms of target vessels compared with the open bypass approach. “As endovascular therapy improves with drug-eluting balloons and other advanced therapies to successfully treat tibial lesions, the angiosome concept will become increasingly important,” she added. “We will have the opportunity to go the extra mile to open up the relevant vessel when given the choice.”

Session 30: CLI and the Angiosome Concept; Reoperations and Reintervention; Other New Concepts and Techniques

Wednesday, 4:39 p.m. – 5:58 p.m.

Grand Ballroom East, 3rd Floor

Traditionally, revascularization procedures for patients with critical limb ischemia (CLI) have focused on the best quality vessel that can be visualized by angiogram, according to Dr. Cynthia Shortell of Duke University Medical Center. An alternative approach is to consider the angiosome to which the affected tissue belongs, but this strategy remains controversial, she noted. On Wednesday afternoon, Dr. Shortell will co-moderate a discussion and debate on applying the angiosome concept to CLI treatment decisions, particularly for patients with tibial disease and tissue loss.

Rates of peripheral arterial disease (PAD) are climbing worldwide, fueled by global population aging and increasing numbers of patients with diabetes mellitus and other risk factors for PAD. Critical limb ischemia, the most severe manifestation of PAD, requires prompt revascularization to prevent severe outcomes such as limb loss and death. When treating lower-limb CLI, vascular surgeons have typically targeted the anterior and posterior tibial arteries instead of the peroneal artery because of their contributions to the pedal arch, Dr. Shortell noted.

But even when conventional revascularization seems to go well, patients can experience poor outcomes such as unhealed wounds and secondary amputation. Because of this problem, some endovascular and vascular surgeons have begun applying the angiosome concept to target vessel selection. Angiosomes are 3-D units of tissue that are fed and drained by specific arteries and veins. “The angiosome concept was first used by plastic surgeons for the purpose of healing flaps, and while it has been introduced to vascular surgery, it has not been embraced widely,” Dr. Shortell said.

Vascular surgeons who use the angiosome concept argue that it can improve vessel selection and vascular access. Some researchers have reported improved ulcer healing and limb preservation after angiosome-based surgical bypass and endovascular approaches. The angiosome concept may be especially useful for vascular reconstructions in patients with renal insufficiency, diabetes, ischemic tissue lesions of the lower limb, and extensive breakdown of collateral vascular networks, according to other studies.

But other CLI experts have asserted that the angiosome concept is not ready for prime time. They have cited a lack of well-designed, prospective trials of large groups of patients, a failure to match patients adequately to compare traditional and angiosome-guided revascularization, and a dearth of data on how the severity of arterial disease affects outcomes.

To help attendees evaluate these issues, Dr. Richard Neville of George Washington University and Dr. Bauer Sumpio of the Yale School of Medicine will kick off Wednesday’s session by debating utility of the angiosome concept for open surgical and endovascular treatment of CLI with gangrenous or ulcerated lesions.
“This will be a great discussion between two experts on the merits of this approach in revascularizing patients with tibial disease and tissue loss,” Dr. Shortell said. “The angiosome concept is an important factor in decision-making around choice of target vessel to revascularize, but it’s not the only one. A good target vessel is still the most important thing, but if given the choice, revascularizing the vessel that is associated with the lesion in question optimizes the chance of wound healing and limb salvage.”

Dr. Shortell also noted that applying the angiosome concept can be more important when using an endovascular approach, which presents more options in terms of target vessels compared with the open bypass approach. “As endovascular therapy improves with drug-eluting balloons and other advanced therapies to successfully treat tibial lesions, the angiosome concept will become increasingly important,” she added. “We will have the opportunity to go the extra mile to open up the relevant vessel when given the choice.”

Session 30: CLI and the Angiosome Concept; Reoperations and Reintervention; Other New Concepts and Techniques

Wednesday, 4:39 p.m. – 5:58 p.m.

Grand Ballroom East, 3rd Floor