Microcirculation. 2015 Nov;22(8):737-43. doi: 10.1111/micc.12249.
The Angiosome Concept Evaluated on the Basis of Microperfusion in Critical Limb Ischemia Patients-an Oxygen to See Guided Study.
- 1Department of Vascular Surgery, University of Erlangen, Erlangen, Germany.
- 2Department of Plastic and Hand Surgery, University of Erlangen, Erlangen, Germany.
- 3Department of Medical Informatics, Biometry and Epidemiology, University of Erlangen, Erlangen, Germany.
Aim of this clinical study was to evaluate the angiosome concept with regard to the microcirculation of the foot in patients with CLI and to evaluate its relevance by means of combined laser Doppler flowmetrie and white-light tissue spectrophotometry.
Twenty-eight patients who underwent leg revascularization in the stage of CLI were prospectively examined. The microperfusion was assessed by light guided spectrophotometry. The measuring points were set according to the angiosome concept into direct and indirect revascularized areas of the foot. Investigations were performed pre and postinterventionally and after 4 and 12 weeks in baseline-position as well as in an elevated position of the leg.
Microcirculation parameters (oxygen saturation, blood flow, velocity) of the revascularized leg showed a significant increase in elevation and baseline position compared to the preoperative values in most analyses. No significant differences between the direct and indirect revascularized angiosome were apparent.
The light-guided spectrophotometry measurement proved to be feasible in terms of measuring changes in the microcirculation after leg revascularization. However, our data do not support the value of the “angiosome concept” concerning the individual changes in microperfusion of the foot in patients with CLI.
angiosome; critical limb ischemia; microcirculation; microperfusion; oxygen to see
In the year of 1987, Taylor and Palmar described a total of 40 angiosomes of the human body . They defined three dimensional blocks of tissue supplied by specific source arteries and veins named angiosomes. Initially, their concept found wide acceptance in the field of free tissue transfer and reconstructive plastic surgery, where pedicled and free flaps were designed on basis of the angiosome concept . In 2006, Attinger et. al. transferred the concept of the angiosomes to the chronic ischemic limb . His approach differentiated between the direct (DR) and the indirect revascularization (IR), meaning a treatment of either tibial vessel, which directly supplies an affected angiosome (DR), or one of the tibial arteries supplying a neighbored angiosomes (IR).
Attinger found six angiosomes of the foot that are fed by the three tibial arteries: the anterior tibial artery (ATA), the posterior tibial artery (PTA) and the peroneal artery (PA). Three angiosomes originate from the PTA. These are the medial calcaneal artery, the lateral plantar artery and the medial plantar artery, which supplies the plantar foot and the medial heel. Two angiosomes are linked to the PA via its anterior perforator and the lateral calcaneal artery supplying the lateral ankle and the lateral heel. The last angiosome is located on the dorsum of the foot and is perfused by the dorsalis pedis artery. Additionally, several arterio-arterial links have been described such as connections between the PA and the PTA (lateral calcaneal branch) in the area of the medial ankle or connections between the PA and the ATA (anterior perforating branch) around the lateral ankle. Furthermore, there are arterial links between the PTA and the ATA around the metatarsals bones .
In recent years a lively discussion about the relevance of the angiosome concept in the setting of tibial interventions of critical ischemic limbs has occurred. A number of retrospective studies have been published with focus on wound healing rates and amputation free survival depending on DR and IR [4-11]. However, it still remains unclear, whether this concept can simply be adapted to the critical limb ischemia patient as a concept of decision making .
Therefore, we tried to evaluate this concept in a different way. As an intact microcirculation is known to be essential for a sufficient wound healing, we focused on the evaluation of the angiosome concept on the level of microperfusion. We therefore hypothesized that there must be a measureable difference in the direct revascularized angiosomes compared to the indirect revascularized angiosomes after revascularization on the level of microcirculation.
In order to assess the microcirculation we made use of a combined method of laser Doppler flowmetry and tissue spectrometry (O2C – Oxygen to see, LEA, Medizintechnik GmbH, Gießen). The device uses white light with the wave length of 500-850 nm as well as laser light with a wave length of 830 nm. The capillary movement of the erythrocytes causes a Doppler shift, which subsequently is detected by the O2C as blood velocity. The amount of erythrocytes detected in the tissue in combination with the velocity yields the overall flow. The emitted white light registers the erythrocyte oxygen saturation and relative hemoglobin amount (sO2 and rHb). SO2 is determined by the color of the blood. The absorption of the white light in the tissue gives indication of the rHb parameter. The higher the light absorption by the tissue, the more hemoglobin the tissue contains. As the rHb did not provide relevant information on the concern of CLI, the measurements were subsequently focused on the parameters sO2, flow and velocity.
The measurements were conducted one day before and after revascularization as well as after 4 and 12 weeks. The specific locations of the probes were distributed according to the angiosome concept as defined by Attinger in the year of 2006 . The investigations were performed in a lying supine position as well in a 45 degree elevation of the leg.
We firstly assessed, whether there was a detectable effect on the overall microcirculation of the foot after macroscopic revascularization. As we found, there was an increase of all cumulated sO2, flow and velocity parameters of the indexed leg after revascularization. This effect showed most distinctly at the first day after revascularization. In the follow up after four and twelve weeks, we measured a slight decrease, which, however, in comparison to the pre values, still signifies a noticeably increase.
We then divided the individual measuring points into direct and indirect revascularized locations, depending on the patients’ individual affected revascularization. After comparing the DR and IR angiosomes, we were unable to detect a significant difference between both on the level of microcirculation. These findings posed a contradiction to our initial hypothesis.
One of the reasons responsible for these findings might be that the angiosome concept initially described by Taylor and Palmer was developed in the course of anatomical studies on patients with a typical healthy – three vessel structure of the lower limb . In contrast, our patients included to this study were all subject to a long history of chronic ischemia. Therefore, the lower leg is subject to a wide collateralization. Furthermore, on the level of microcirculation, the so called choke vessels might be reperfused in the state of chronic ischemia and therefore link the particular angiosomes between each other, which might serve as a further system of collateralization.
In conclusion, this study is the first evaluating the angiosome concept in the chronic ischemic limb prospectively. Contrary to our hypothesis, we could not verify the angiosome concept in the chronic ischemic limb on the level of microcirculation. Due to our findings we cannot confirm an uncritical adaption of the angiosome concept as a model of decision making in the chronic ischemic limb.
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