**3. Interconnections**

A number of interconnections exist between the angiosomes. When present, these intercon‐ nections exist *a priori* and – in contrast to the choke vessels described below - do not need a period of ischemia to open. However, as peripheral arterial disease progresses, these con‐ nections may be blocked.

principle works for the transfer of skin grafts from essentially normal donor sites. These re‐ sults may, however, not be extrapolated to other situations e.g. in the ischemic foot where distal, aggressive macroangiopathy is associated with microcirculatory changes like throm‐

The Role of The Angiosome Model in Treatment of Critical Limb Ischemia

http://dx.doi.org/10.5772/54418

429

(a)

(b)

**Figure 2.** A. Lateral oblique projection of the anterior pedal vessels of a patient with peripheral occlusive arterial dis‐ ease and patent arterial-arterial connections. ALMB-APB: Connection between the anterior lateral malleolar branch of the anterior tibial artery and the anterior perforating branch of the peroneal artery. DPA-LPA: Perforating branch con‐ necting the dorsal pedal artery with the lateral plantar artery. B. Antero-posterior projection of the perforating branch

connecting the dorsal pedal artery with the lateral plantar artery (DPA-LPA).

bosis, neuropathy, local sepsis, arterio-venous shunting and hypercoagulability [9].

The arterial-arterial connections include:

Anterior tibial to peroneal:

The lateral malleolar artery joins with the anterior perforating branch of the peroneal artery just above the ankle joint (Figure 2A).

### *Anterior tibial to posterior tibial:*

The lateral plantar artery forms the deep plantar arch crossing the proximal 2,3, and 4th meta‐ tarsals and finally anastomoses directly with the dorsalis pedis artery in the first interspace (Fig‐ ures 2A and 2B). The superficial and deep medial plantar arteries join at the cruciate anastomosis. Depending on what arteries predominate at or around the cruciate anastomosis, the hallux may be primarily nourished by the lateral plantar artery, medial plantar artery, the first dorsal metatarsal artery or simultaneously by either two or three of these arteries [7].

The medial plantar artery also interconnects with the anterior tibial tree as cutaneous branches connect proximally with medial branches of the dorsalis pedis artery and distally with branches of the first dorsal metatarsal artery.

#### *Peroneal and posterior tibial connections:*

Between one and three communicating branches between the peroneal artery and the poste‐ rior tibial artery proximal to the ankle joint deep to the Achilles tendon.

On the other hand, no direct arterial-arterial connection exists between the medial and later‐ al calcaneal arteries, which both supply the plantar aspect of the heel.
