Catheterization and Cardiovascular Interventions 83:130–131 (2014)
Editorial Comment Arterial Access for Limb Salvage for Critical Limb Ischemia: How Low (and How Small) Can We Go? Robert D. Safian,* MD, FSCAI Department of Cardiovascular Medicine (Beaumont Health System) and the William Beaumont Oakland University School of Medicine, Royal Oak, Michigan
The presence of critical limb ischemia (CLI) identifies a patient with a high risk for cardiovascular mortality and limb loss, and mandates strong interdisciplinary collaboration between endovascular interventionalists, vascular surgeons, wound care specialists, cardiologists, and medical specialists with expertise in management of diabetes, chronic kidney disease, and infectious diseases. From a cognitive standpoint, two inter-related clinical principles have emerged that have significant clinical relevance for CLI patients [1]. The first is the angiosome concept, which identifies six anatomic units in the foot, each consisting of discrete regions of arterial blood flow. The anterior tibial/dorsalis pedis artery supplies one angiosome (primarily the dorsum of the foot); the posterior tibial artery supplies three angiosomes via the calcaneal branch (medial plantar surface of the heel), the medial plantar artery (the medial plantar surface of the foot), and the lateral plantar artery (the great toe and most of the plantar surface of the foot except for the lateral heel); and the peroneal artery supplies two angiosomes via the anterior perforating branch (area overlying the lateral malleolus) and the calcaneal branch (lateral and plantar surface of the heel). The second is the concept of direct versus indirect revascularization; direct revascularization requires straight in-line revascularization of the artery that supplies the affected angiosome, whereas indirect revascularization relies on improvement in collateral blood flow to the affected angiosome via the pedal arch, usually because direct revascularization is not technically feasible. In terms of limb salvage, the major goals are to avoid or to limit the extent of amputation, promote wound healing, and provide the patient with a functional limb, to the extent allowable by surgical bypass and/or percutaneous revascularization. From a technical perspective, there have been truly remarkable achievements in percutaneous revascularization of the superficial femoral artery, includC 2013 Wiley Periodicals, Inc. V
ing antegrade femoral and retrograde popliteal approaches, relying on angiographic and ultrasound roadmaps to enhance procedural safety, and intraluminal and subintimal crossing techniques to enhance procedural success. There is growing interest in direct pedal access for retrograde recanalization, when antegrade recanalization is not feasible [2]. Incredibly, in this issue of Catheterization and Cardiovascular Intervention, Palena et al. demonstrate further ingenuity by performing direct access to the first dorsal metatarsal artery in 38 patients with infrapopliteal disease and CLI refractory to “standard” antegrade femoral or retrograde pedal approaches [3]. In this remarkable study, the authors achieved direct revascularization of the affected angiosome in 33 of 38 patients (87%), resulting in marked improvement in transcutaneous oxygen tension, avoidance of major amputation, amputation-free survival in 81.5% at 12 months, and absence of serious complications. However, significant challenges with this technique include the requirement for angiographic roadmapping to achieve arterial access (which may be problematic when tibial blood flow is poor), high radiation exposure due to prolonged fluoroscopy times, and technical failure in 13.5% due to refractory vasospasm or obliterative atherosclerosis precluding guidewire crossing of tibial artery occlusions. Furthermore, although the strategy of direct revascularization is associated with faster wound healing, direct and indirect revascularization seem to be associated with similar rates of subsequent amputation, raising a question as to the need for transmetatarsal recanalization [4]. Nevertheless, the technical achievements are impressive, and the study demonstrates just “how low (and how small) we can go.” Further improvement in ultrasound guidance and in
Conflict of interest: Nothing to report. *Correspondence to: Robert D. Safian, MD, FSCAI, Center for Innovation and Research in Cardiovascular Diseases (CIRC), Beaumont Health System, Professor of Medicine, Oakland University William Beaumont School of Medicine, Royal Oak MI 48073. E-mail: [email protected] Received 6 November 2013; Revision accepted 10 November 2013 DOI: 10.1002/ccd.25289 Published online 18 December 2013 in Wiley Online Library (wileyonlinelibrary.com)
Arterial Access for Limb Salvage for Critical Limb Ischemia
guidewire and sheath technology may further enhance procedural success, and provide endovascular specialists with additional opportunities for limb salvage in patients with CLI and limited options for revascularization. REFERENCES 1. Lida o, Nanto S, Uematsu M, et al. Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia. Cathet Cardiovasc Interv 2010;75:830–836.
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2. Rogers RK, Dattilo PB, Garcia JA, Tsai T, Casserly IP. Retrograde approach to recanalization of complex tibial disease. Cathet Cardiovasc Interv 2011;77:915–925. 3. Pelena LM, Crocco E, Manzi M. The clinical utility of below-the-ankle angioplasty using transmetatarsal artery access in complex cases of CLI. Catheter Cardiovasc Interv 2014;84:123–129. 4. Kabra A, Suresh KR, Vivekanand V, Vishnu M, Sumanth R, Nekkanti M. Outcomes of angiosome and non-angiosome targeted revascularization in critical limb ischemia. J Vasc Surg 2013;57:44–49.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Editorial Comment Arterial Access for Limb Salvage for Critical Limb Ischemia: How Low (and How Small) Can We Go? Robert D. Safian,* MD, FSCAI Department of Cardiovascular Medicine (Beaumont Health System) and the William Beaumont Oakland University School of Medicine, Royal Oak, Michigan
The presence of critical limb ischemia (CLI) identifies a patient with a high risk for cardiovascular mortality and limb loss, and mandates strong interdisciplinary collaboration between endovascular interventionalists, vascular surgeons, wound care specialists, cardiologists, and medical specialists with expertise in management of diabetes, chronic kidney disease, and infectious diseases. From a cognitive standpoint, two inter-related clinical principles have emerged that have significant clinical relevance for CLI patients [1]. The first is the angiosome concept, which identifies six anatomic units in the foot, each consisting of discrete regions of arterial blood flow. The anterior tibial/dorsalis pedis artery supplies one angiosome (primarily the dorsum of the foot); the posterior tibial artery supplies three angiosomes via the calcaneal branch (medial plantar surface of the heel), the medial plantar artery (the medial plantar surface of the foot), and the lateral plantar artery (the great toe and most of the plantar surface of the foot except for the lateral heel); and the peroneal artery supplies two angiosomes via the anterior perforating branch (area overlying the lateral malleolus) and the calcaneal branch (lateral and plantar surface of the heel). The second is the concept of direct versus indirect revascularization; direct revascularization requires straight in-line revascularization of the artery that supplies the affected angiosome, whereas indirect revascularization relies on improvement in collateral blood flow to the affected angiosome via the pedal arch, usually because direct revascularization is not technically feasible. In terms of limb salvage, the major goals are to avoid or to limit the extent of amputation, promote wound healing, and provide the patient with a functional limb, to the extent allowable by surgical bypass and/or percutaneous revascularization. From a technical perspective, there have been truly remarkable achievements in percutaneous revascularization of the superficial femoral artery, includC 2013 Wiley Periodicals, Inc. V
ing antegrade femoral and retrograde popliteal approaches, relying on angiographic and ultrasound roadmaps to enhance procedural safety, and intraluminal and subintimal crossing techniques to enhance procedural success. There is growing interest in direct pedal access for retrograde recanalization, when antegrade recanalization is not feasible [2]. Incredibly, in this issue of Catheterization and Cardiovascular Intervention, Palena et al. demonstrate further ingenuity by performing direct access to the first dorsal metatarsal artery in 38 patients with infrapopliteal disease and CLI refractory to “standard” antegrade femoral or retrograde pedal approaches [3]. In this remarkable study, the authors achieved direct revascularization of the affected angiosome in 33 of 38 patients (87%), resulting in marked improvement in transcutaneous oxygen tension, avoidance of major amputation, amputation-free survival in 81.5% at 12 months, and absence of serious complications. However, significant challenges with this technique include the requirement for angiographic roadmapping to achieve arterial access (which may be problematic when tibial blood flow is poor), high radiation exposure due to prolonged fluoroscopy times, and technical failure in 13.5% due to refractory vasospasm or obliterative atherosclerosis precluding guidewire crossing of tibial artery occlusions. Furthermore, although the strategy of direct revascularization is associated with faster wound healing, direct and indirect revascularization seem to be associated with similar rates of subsequent amputation, raising a question as to the need for transmetatarsal recanalization [4]. Nevertheless, the technical achievements are impressive, and the study demonstrates just “how low (and how small) we can go.” Further improvement in ultrasound guidance and in
Conflict of interest: Nothing to report. *Correspondence to: Robert D. Safian, MD, FSCAI, Center for Innovation and Research in Cardiovascular Diseases (CIRC), Beaumont Health System, Professor of Medicine, Oakland University William Beaumont School of Medicine, Royal Oak MI 48073. E-mail: [email protected] Received 6 November 2013; Revision accepted 10 November 2013 DOI: 10.1002/ccd.25289 Published online 18 December 2013 in Wiley Online Library (wileyonlinelibrary.com)
Arterial Access for Limb Salvage for Critical Limb Ischemia
guidewire and sheath technology may further enhance procedural success, and provide endovascular specialists with additional opportunities for limb salvage in patients with CLI and limited options for revascularization. REFERENCES 1. Lida o, Nanto S, Uematsu M, et al. Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia. Cathet Cardiovasc Interv 2010;75:830–836.
131
2. Rogers RK, Dattilo PB, Garcia JA, Tsai T, Casserly IP. Retrograde approach to recanalization of complex tibial disease. Cathet Cardiovasc Interv 2011;77:915–925. 3. Pelena LM, Crocco E, Manzi M. The clinical utility of below-the-ankle angioplasty using transmetatarsal artery access in complex cases of CLI. Catheter Cardiovasc Interv 2014;84:123–129. 4. Kabra A, Suresh KR, Vivekanand V, Vishnu M, Sumanth R, Nekkanti M. Outcomes of angiosome and non-angiosome targeted revascularization in critical limb ischemia. J Vasc Surg 2013;57:44–49.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
