Abstract
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 ( s elective a rterio- v enous e ndoluminal s witch) 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.
1
Introduction
Advanced atherosclerosis with extended tibial arteries lesions is a common concern in diabetic patients having critical-limb ischemic (CLI) wounds and often challenges the classical methods for revascularization. Despite progresses in both surgical and endovascular approaches, in 14–20% of these patients exhibiting advanced below the knee occlusive disease, neither of the available procedures can afford appropriate distal arterial supply, turning to amputation . This observation was documented particularly in diabetic ischemic limbs, that currently add a neuropathic background, local sepsis and variable amounts of tissue loss . Although the concept of “venous arterializations” as extreme alternative for delivering the oxygenated blood to the distal tissues is not new, increasing contemporary experience seems to reconsider this farthest alternative for limb revascularization in certain desperate cases at high risk for amputation . While some reports are claiming encouraging limb rescue results , others remain reserved . Parallel efforts for CLI limb salvage were equally unfolded in the plastic surgery field, by introducing an “angiosomes model for revascularization” (AMR), that proposes targeted tissue reconstructions upon specific bundles for arterial and venous blood supply . We examined in this study a hybrid technique (surgical and endovascular) for deep calf veins selective arterializations, in conventionally inoperable diabetic CLI foot ulcers, appending an intentional AMR policy to support tissue regeneration.
2
Material and methods
2.1
Patients
Since January 2001 until September 2009, a series of 26 limbs in 25 diabetic patients with imminent amputation for threatening inferior limb ischemic wounds and no feasible arterial revascularizations, were treated by selective arteriovenous endoluminal switch (SAVES method) in the deep calf veins following an AMR policy . One patient received a staged bilateral intervention, at 1-year interval. These files were retrospectively reviewed having an ethical committee approval. Patient’s selection was discussed in a multidisciplinary staff gathering vascular surgeons, interventional radiologists, diabetologists, orthopedic and plastic surgeons, infectiologists and general practitioners ( Table 1 ).
| Type of the last conventional Therapy that failed before selecting for the SAVES technique | n =26 | Background history of the latest arterial revascularization | ||||||
|---|---|---|---|---|---|---|---|---|
| No feasible aterial revasc. | Primary procedure | Secondary procedure after: | Tertiary procedure after: | |||||
| Endovascular | Surgery | Endovascular | Surgery | |||||
| Failed femoro-infra-popliteal bypass | ( n =2) | 1 | 1 | |||||
| Failed femoro-tibial bypass | ( n =6) | 1 | 3 | 1 | 1 | |||
| Failed femoro-pedal bypass | ( n =4) | 1 | 1 | 1 | 1 | |||
| Failed btk. angioplasties (intra- or extraluminal) | ( n =6) | 1 | 3 | 2 | ||||
| Failed btk. stenting | ( n =2) | 1 | 1 | |||||
| Failed laser therapy | ( n =1) | 1 | ||||||
| Unsuccessful iloprost infusion | ( n =2) | 1 | 1 | |||||
| Unsuccessful vasodilatator+anticoagulant treatment | ( n =2) | 1 | 1 | |||||
There were 18 men and the mean age was 71.9 years (in the range 56–84). Seven (27%) cases were insulin dependent. Patient characteristics and risk factors are summarized in Table 2 . The main inclusion criteria expressed the presence of distal foot ulcerations and tissue necrosis (Rutherford categories 5–6.) and were assigned in all the treated limbs. Severe ischemic wounds strictly confined to the foot (Wagner Grade 3–4) were noted in 18 limbs (69%), whereas 8 (31%) others, associated complex foot and below the knee trophic lesions ( Table 2 ). Other inclusion criteria gathered critical levels of trans-cutaneous oxymetry (tcPO2 <30 mmHg) in previously failed revascularizations without feasible arterial reconstructions ( Tables 1 and 2 ), joining the lack of autologous venous material ( Table 3 ) and the presence of extended tissue inflammation ( n =20 cases) ( Table 2 ).
| No. of Limbs ( n =26) | (n%) | |
|---|---|---|
| Age >70 years | n =9 | 34% |
| Coronary disease | n =23 | 88% |
| Chronic renal insufficiency | n =15 | 57% |
| End stage renal disease/dialysis | n =11 | 42% |
| Associated venous insufficiency | n =7 | 26% |
| Cerebrovascular disease | n =9 | 34% |
| Inferior limb neuropathy | n =23 | 88% |
| Clinical features | No. of limbs | % |
| Failed previous primary or iterative femoro-distal bypasses | n =12 | 46% |
| Failed previous primary or iterative endovascular attempts | n =9 | 34% |
| Sole medical treatment and no feasible previous arterial revascularization | n =4 | 15% |
| Foot and calf wounds or inflammation impairing distal exposure of vessels | n =20 | 77% |
| Wagner Grade 3 foot lesions. | n =7 | 26% |
| Wagner Grade 4 foot lesions. | n =19 | 73% |
| Wagner Grade 3 and 4 foot lesions added to calf or ankle trophic defects | n =8 | 31% |
| Angiographic features | No. of limbs | % |
| 2 or 3 crural arteries occluded | n =15 | 57% |
| Incomplete or occluded pedal arches | n =11 | 42% |
| Spread of calcifications >5 cm | n =13 | 50% |
| Infra-popliteal occlusions >10-cm length | n =16 | 61% |
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