Attractive theory of angiosome-directed revascularization is a widely accepted concept, helping interventionist to plan their infrapopliteal angioplasty; this theory was developed as an effort of plastic surgeon (Ian Taylor since 1987) [11] It provides not only the guidelines for choice of the target artery, but also influence the indications for endovascular or open repair according to which target artery is accessible by which method.
In this study, EVT was the primary choice for the management of all CLI patients due to BTK lesions even young patients those are generally fit for anesthesia.
A study done by Iida et al. [10] suggested that achieving direct flow based on the angiosome concept gives better results in freedom from MA, AFS, and MALE. Clinically, successfully achieving arterial perfusion to an ulcer by angioplasty was limited in comparison to the surgical bypass; therefore, the angiosome concept is considered relatively important for both modalities of revascularization, especially the EVT.
Azuma et al. [14] concluded that all previous studies to compare the results of direct vs indirect revascularization were retrospective and thus, liable for heterogeneity in patient selection. Also, the angiosome-specific artery will also be the most diseased artery while we most probably select the least atherosclerotic patients to the “direct revascularization” group.
Azuma et al. [14] also suggested that we should attempt the direct revascularization firstly and only go to the indirect revascularization option when this attempt failed. He stated that the preoperative variability in disease extent reflects the differences in healing rate and limb salvage between groups.
Some authors do infrapopliteal intervention in claudicants as Melki et al. and Soder et al. [15, 16] usually in association with proximal disease intervention as true lifestyle limiting claudications from isolated infrapopliteal disease is rare. Indications of intervention in this study were gangrene in 23 limbs (43.9%) and non-healing ulcers in 32 limbs (56.1%) with or without rest pain. The complication rate from infrapopliteal PTA procedures was minimal, only five cases during the procedures, and may make us offer infrapopliteal PTA in our claudicant patients.
As regards methods of crossing the lesions, Wang et al. [17] stated that 0.014-in. hydrophilic-coated can cross the stenosis and penetrate occlusive lesions. However, it is not possible to provide enough support to cross extremely long occlusions, and it cannot replace the 0.035-in. hydrophilic-coated guide wire (Wang et al.) [17]. In our study, we used 0.014 in five cases and 0.018 in 35 cases of total occlusions and 0.035 in 15 cases of total occlusions. Crossing stenosis with 0.014 is usually straightforward but crossing the occlusions is very challenging, so if we have long occlusions that are uncrossable with 0.014 wire, we usually cross with 0.018 or 0.035 and then we exchange the larger wire through an exchange catheter, continue the PTA on 0.014 with a long low profile balloons to minimize the number of inflations, and reduce complications.
The lesions in our study were TASC-B in 11 patients (12 limbs), TASC-C in 16 patients (18 limbs), and TASC-D in 23 patients (25 limbs). This means that a high technical success rate can be achieved even in situations traditionally considered unfavorable for angioplasty.
Fusaro et al. [18] restored the continuity between plantar and dorsalis pedis arteries using subintimal angioplasty (SIA) in an 84-year-old lady who presented with ischemic foot ulcer. We have used this technique in eight cases when transluminal crossing of the lesions is impossible, and in two cases, we failed to cross by either technique (20% failure rate of SIA). We have not found this technique easy as it appears in Bolia publications [19] that is why we reserved it to cases of failed transluminal crossing.
Scheinert et al. [20] presented the follow-up data of 112 patients treated with either PTA or PTA+ stent in the infrapopliteal vessels in 2004 concluding that 1-year patency rates were significantly superior with 83% in the stented group. A study done by Graziani et al. [21] showed that PTA alone is successful in salvaging 90% of the limbs. In our study, PTA only was done in all cases, as we believed that the late occlusion of the PTA did not affect the limb salvage rate and recanalization temporarily increases blood flow to the foot and has a positive effect in eradicating infection and healing ulcers and surgical wounds. As foot tissue healing reduces oxygen demand, less blood flow is generally required to maintain tissue integrity and keep the limb asymptomatic.
We tried the retrograde approach in only two cases (we punctured the dorsalis pedis artery and successfully recanalized its proximal portion; also, we punctured posterior tibial artery and successfully recanalized its mid-portion). It has been clearly shown that the retrograde approach is a highly successful option in patients with no antegrade access as has been shown by Montero-Baker et al. [22].
One puncture site hematoma occurred and managed conservatively while three perforations of the target vessel was managed by sustained balloon inflation across the perforation for 3 min, and all of them did not affect the outcome. So, the overall procedural complications were only four cases (7% of cases).
The follow-up after intervention was every month. All the patients’ examination was completed at the 12th month. Nine patients (18%) were lost during follow-up. AFS and MALE are defined as MA or any re-intervention and MA compared between the groups using Kaplan-Meier curves.
Iida et al. [10], on a study done during 4 years follow-up on 203 limbs in 177 consecutive patients with CLI treated by endovascular approaches. The results were significantly higher limb salvage rate in patients with direct revascularization than the indirectly revascularized wounds. Also, they postulated that it is not important how much blood can be provided to the foot but rather whether it reaches the ischemic area.
As regards, AFS between the two cohorts, after 1 year follow-up, was 75% in the direct group vs 67% in the indirect group. This percentage on a study done by Iida et al. [10] found to be 71 ± 4% in the direct group vs 50 ± 5% in the indirect group at 1 year and 49% ±8% vs 29 ± 6% at 4 years, respectively (P = .0002(.
In the study done by Iida et al. [23], the estimated freedom from MALE percentage was 61 ± 5% in the direct group vs 53 ± 5% in the indirect group at 1 year follow-up, and after 4 years follow-up, the percentage was 51 ± 8% vs 28 ± 8%, respectively (P = .008(. Also, the percentage of freedom from MA was 85 ± 4% in the direct group vs 74 ± 5% in the indirect group at 1 year, and after 4 years, it was 82 ± 5% vs 68% ± 5%, respectively (P = .01).
Open bypass surgery should be restricted to lesions technically unsuitable for EVT or patients who did not benefit from angioplasty. This was concluded by Ryer et al. [24] who considered the PTA as the first line of treatment for high-risk patients or those lacking an autogenous conduit. Other authors support the fact that PTA and surgical revascularization can be used sequentially and do not exclude each other [25]; for all these reasons, PTA is currently considered as the procedure of the first choice in diabetic subjects with ischemic foot ulcer and is not limited to those patients who cannot undergo an operation while surgery is considered a second-line procedure after PTA.
There are many limitations for this study. Firstly, it was a non-randomized analysis and the characteristic baselines were similar on the studied groups. Secondly, healing time and the details of the ulcer regarding size and depth were not evaluated and not compared in both groups. Thirdly, the angiographic follow-up was not obtained. It is promising to do a multicenter prospective cohort study model to combat these issues.