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Vlad Alexandrescu1, Gerard Hubermont21Department of Vascular Surgery, Princess Paola Hospital, Marche- en-Famenne, Belgium; 2Department of Diabetology, Princess Paola Hospital, Marche-en-Famenne and Sainte-Thérèse Hospital, Bastogne, BelgiumAbstract: The angiosome principle was first described by Jan Taylor in 1987 in the plastic reconstructive surgery field, providing useful information on the vascular anatomy of the human body. Specifically concerning foot and ankle pathology, it may help the clinician to select better vascular access and specific strategies for revascularization. This knowledge may be particularly beneficial when treating diabetic neuroischemic foot wounds associated with particularly aggressive atherosclerotic disease and a poor collateral circulation. The implementation of angiosome-based strategies in diabetic infragenicular vascular reconstruction may afford encouraging wound healing and limb preservation rates using both bypass and endovascular techniques. The minimal invasiveness of these novel strategies enables us to perform more specific and more distal tibial and/or foot arterial reconstructions, in one or multiple targeted vessels. This paper reviews the available literature on this revascularization strategy and focuses on the potential benefit of angiosome-guided primary angioplasty for diabetic ischemic foot ulcers.Keywords: critical limb ischemia, diabetic foot, limb salvage, angiosomes, angioplasty

Purpose: To evaluate the technical and clinical outcomes of primary subintimal (SA) and endoluminal angioplasty (EA) guided by an angiosome model of revascularization in diabetic patients with critical limb ischemia (CLI) and Wagner grade 1DS4 foot ulcers.Methods: A retrospective review was undertaken of 98 diabetic CLI patients (68 men; mean age 72.8 years, range 46-94) who presented to our institution from January 2005 to January 2008 for treatment of Wagner grade 1-4 foot ulcers involving 124 limbs. Following the angiosome model of perfusion in the foot and ankle, the target arterial lesions in the 124 limbs were treated with 80 (64%) associated SA and EA procedures, 21 (17%) multilevel EAs, and 23 (18%) single SA techniques.Results: Initial technical success was achieved in 102 (82%) interventions: 82/103 SAs and 20/21 of the EAs. The 30-day survival rate was 98% (1 fatal myocardial infarction). The cumulative rates of primary and secondary patency, limb salvage, and clinical success were: 57%±4%, 71%±4%, 91%±3%, and 85%±3% at 12 months and 48%±5%, 61%±4%, 84%±6%, and 73%±6% at 32 months, respectively. Limb salvage appeared to be negatively affected at 3 years by the presence of Wagner grade 3-4 lesions (p<0.0002), the bedridden condition of patients (p<0.0001), end-stage renal disease (p<0.0001), left ventricular dysfunction (p<0.0001), and peripheral neuropathy (p=0.023). Using the angiosome approach, complete healing of ulcers with or without minor amputation was seen in 79% (98/124 limbs), while 62 of 70 Wagner grade 1-2 and 36 of 54 Wagner 3-4 foot lesions healed in the first 1 to 3 months after revascularization.Conclusion: Targeted primary angioplasty following the angiosome model could be an effective therapeutic method in the ulcer healing process. However, beyond appropriate revascularization, aggressive control of concurrent risk factors in diabetic wound healing probably plays an equally relevant role. [ABSTRACT FROM AUTHOR]

The angiosome model was first pioneered by Jan Taylor in 1987 by his influential anatomical works in the plastic reconstructive surgery field. The concept depicts the human body into three-dimensional blocks of tissue, fed by specific arterial and venous irrigation sources, the "angiosomes". Adjacent angiosomes are linked by a vast compensatory collateral web "the choke vessels". This collateral network provides a remarkable "rescue system" in non-atherosclerotic and non-diabetic patients. However, it could be dramatically damaged in chronic limb ischemia (CLI) subjects witnessing miscellaneous systemic arterial disease. The angiosome concept may provide useful information on the human vascular anatomy and related pathology, with specific applications in surgical and vascular interventional therapies. This knowledge may become particularly beneficial in CLI while treating advanced atherosclerotic disease that adds extended collateral depletion. The concept may allow to deliberately focus arterial flow reconstruction in specific limb ischemic areas that exhibit tissue loss and fluctuating "rescue-vessels" supply. The implementation of angiosome-derived strategies in Rutherford grade III CLI presentations, may afford encouraging wound healing and limb preservation rates for both, bypass or endovascular techniques. The present paper proposes a parallel review of the main contemporary publications that share this theory in dedicated CLI literature, with practical considerations for its daily use. Recent applications of the angiosome concept in current CLI revascularization seem to evince benefic results in tissue cicatrization, although comparative and prospective data are further mandatory to cast any pertinent clinical validation.

Few data are available focusing on controlled blunt microdissection during below-the-knee interventions as sole or synchronous technique coupled to subintimal angioplasty, particularly in the management of diabetic critical-ischemic foot wounds. We present two cases of targeted recanalizations in the tibial and pedal trunks for plantar and forefoot diabetic ischemic tissue defects, following an angiosome-model for perfusion.

Purpose: To evaluate the clinical benefit in wound healing and limb preservation after primary below-the-knee angioplasty guided by an angiosome model of perfusion in diabetic patients with neuroischemic foot ulcers., Methods: From September 2001 to April 2010, 232 limb-threatening neuroischemic wounds in 208 diabetic patients (147 men; mean age 74.3 years, range 42-97) were treated by below-the-knee endoluminal and/or subintimal angioplasty. There were 19 (8%) TASC II type B, 80 (34%) type C, and 133 (57%) type D infrapopliteal lesions. Patients treated prior to 2005 when the angiosome-targeted revascularization protocol was introduced (89 limbs, group 1) were compared to 134 limbs treated subsequently according to the angiosome model (group 2). The angiosome-oriented group 2 included 25% procedures focusing on the anterior tibial and dorsalis pedis arteries, 68% on the posterior tibial and plantar vessels, and 7% on the peroneal arteries., Results: The global technical success was 80% (187/232): 82% in group 1 and 79% in group 2. The cumulative patient survival rates were 90%, 78%, and 65% in group 1 and 93%, 82%, and 71% in group 2 at 12, 24, and 36 months, respectively (p = 0.545). At the same time points, the freedom from amputation rates were 84%, 79%, and 79% in group 1 versus 90%, 89%, and 89% in group 2 (p = 0.035). Clinical success rates were 76%, 68%, 68% in the group 1 and 85%, 79%, and 79% in group 2 (p = 0.025). Primary and secondary patency rates did not differ between groups (p = 0.813 and p = 0.511). Patients in group 2 treated with angiosome-targeted revascularization had significantly better wound healing (p<0.018) and limb preservation (p<0.030)., Conclusion: Below-the-knee first-line angioplasty guided by an angiosome model may prove beneficial in terms of better wound healing of diabetic foot ulcers and subsequent limb salvage. Further technical improvements and large comparative studies are necessary to support these observations.

Aim of the Study: The study proposes to evaluate the limb salvage in diabetic ischemic limbs with foot wounds, where all types of common arterial reconstructions have previously failed or were impracticable, by using the "SAVES" technique (selective arterio-venous endoluminal switch) for deep calf veins arterialization upon an angiosomes model of distribution., Materials and Methods: Since January 2001 until September 2009, a series of 26 limbs with threatening ischemic wounds in 25 diabetic patients at high risk for major amputation and no feasible conventional revascularizations, were treated by the hybrid (surgical and endovascular) SAVES technique and were retrospectively reviewed. The method consists in selective arterialization of the deep calf veins with synchronous endoluminal exclusion of the collaterals, guided by an angiosomes- model of vascularization. There were 12 limbs treated by preferential anterior tibial veins arterialization, 11 with revascularizations in the posterior tibial and three others targeting the peroneal-related territorial wound distribution., Results: The initial technical success was achieved in 21 of 26 limbs (80%) with 0% 30-day perioperative mortality rate. The cumulative primary and secondary patency were: 66%, 60% and 48%, at 12, 24 and 36 months, respectively. Limb salvage revealed 73% at one year and steady 73% afterwards, while the clinical success was: 68%, 60% and 60% at identical time intervals., Conclusion: Selective deep calf venous arterialization oriented by an angiosome model for reperfusion may represent a complementary alternative for limb salvage in extreme situations, inoperable by direct arterial methods. Larger groups of study are needed to ascertain these preliminary observations., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Lead was administered to male and female rats in drinking water for 3 and 6 weeks at the following doses: 0, 10, 100, 1000, 5000 ppm and for 6 months at 10 ppm only. Various parameters of blood - lead concentration (Pb-B), hematocrit (Htc), hemoglobin (Hb), free erythrocyte porphyrins (FEB), delta-aminolevulinate dehydratase (ALAD), reticulocytes - and tissue - ALAD, free tissue porphyrins (FTP), lead concentration (Pb-T) - were determined. Pb-B increases with dose but reaches rapidly a plateau despite continuous Pb administration. Concentration of Pb in kidney, liver and brain correlates with Pb-B. Pb does not accumulate in heart. Kidney is the main site of Pb deposition and kidney ALAD is the parameter most susceptible to lead, since reduction is observed in all treated groups after 3 weeks of exposure. However, kidney ALAD inhibition is transitory since after 6 weeks it is only observed in the 5000 ppm group. At 10 ppm lead prevents also the increase in blood ALAD activity normally associated with the reticulocytosis of repetitive bleeding. The next parameters affected by lead are: ALAD in blood which is inhibited after 6 weeks of treatment with 100 ppm lead, and FEP, delta-aminolevulinic acid plus other pyrrole-forming substances in urine (ALA-U), and FTP in kidney which are increased after 3 or 6 weeks of treatment with 1000 and 5000 ppm lead.

Lead was administred to adult female rats in drinking water (0;0.1:1 and 10 ppm) for 3 weeks before mating, during pregnancy and during 3 weeks after delivery. On day 21 after delivery the mothers and their newborns were sacrified and various parameters of blood -- lead concentration on (Pb-B), hematocrit (Htc), hemoglobin (Hb), free erythrocyte porphyrins (FEP), delta0aminolevulinate dehydratase (ALAD) -- and tissue -- ALAD, free tissue porphyrins (FTP), lead concentration (Pb-T) -- were determined. In mothers a significant increase in Pb-B and Pb concentration in kidney was found in the 10 ppm group, but this increase in lead concentration was not associated with any statistically significant modification of the biochemical parameters. In newborns, lead concentration in blood and in kidney was also significantly increased in the 10 ppm group and this lead exposure was associated with a decrease of the ALAD activity in blood and an increase of FTP in kidney. On the basis of the biochemical parameters investigated one can therefore conclude that the developing organism is more susceptible to the biological action of lead than the organism of adult animals and that the "no-effect" level of lead administered during pregnancy and in the neonatal period is around 1 ppm.

Blood-lead level (Pb-B), erythrocyte delta-aminolevulinic acid dehydratase (ALAD) activity, free erythrocyte porphyrin (FEP) concentration, delta-aminolevulinic acid concentration in urine (ALAU), hematocrit value, and hemoglobin concentration were compared for groups of children 10-13 years old from areas differently polluted by lead (rural area and lead smelter area). The biological responses of the children were also compared with those observed in adults similarly exposed to lead (Pb-B: 10-40 mug/100 ml). Compared with the rural children, children living less than 1 km from the smelter exhibited a significant increase of Pb-B and FEP, a significant inhibition of ALAD, and a slight positive correlation of ALAU with Pb-B; however, they showed no biological signs of anemia. In children living approximately 1.5 km from the smelter, there was still a significant increase of Pb-B and a concomitant inhibition of ALAD, but no change in FEP concentration. Comparison of the dose-response curves between Pb-B and FEP in adult males, adult females, and children indicates that the sensitivity to lead is in the order of children larger than or equal to women greater than men. Based on the FEP response, it is proposed that 25 mug Pb/100 ml blood be regarded as the maximum biologically allowable concentration of lead in blood of school-age children.