**7. Discussion**

whom only indirect revascularization was possible. In this review the finding was con‐ firmed after propensity matching of groups. In multivariate analysis, elevated levels of c-re‐ active protein were found to be independent predictors of major amputation in the indirect revascularization group but not in the direct revascularization group. This may imply that

Alexandriescu and collegues have published several reports describing their experience with targeted primary angioplasty of diabetic foot lesions [16-17]. In a series of 124 limbs (98 patients), they were able to achieve direct revascularization in 82% [16]. Limb salvage was 91% at 12 months and 84% at three years follow-up. More recently, they published a histori‐ cal comparison between their results before and after 2005 when they introduced the angio‐ some concept in their practice. Despite similar graft patency and technical success, they experienced a significantly better wound healing rate and limb preservation in the group of patients treated according to the angiosome concept [18]. This result is interesting although

In a paper published together with Alexandriescu, the vascular surgery department at the University Hospital in Helsinki, Finland recently reported their results from the last three years [19]. In a population including approximately the same number of direct and indirect endovascular revascularizations, they found 74% of the wounds to have healed within one year in the directly revascularized group compared to 46% in the indirectly revascularizd

Two studies, one surgical by Deguchi [20] and one endovascular by Blanes Ortí [21] failed to show any difference in wound healing time or limb salvage between directly or indirectly revascularized patients. Due to small numbers, the statistical strengh of these comparisons

The prognostic significance of indirect revascularization via collaterals was studied by Vare‐ la in a mixed cohort of venous bypass and endovascular treated patients with ischemic wounds [22]. Defining collaterals visible on perioperative angiograms, either between distal calcaneal peroneal branches and anterior or posterior tibial artery (n=16) or patent pedal arch connecting dorsal and plantar blood supply (n=2), they found a similar wound healing rate for indirect revascularization of the wound area through collaterals as for direct revas‐ cularization to the angiosome specific feed artery (92% versus 88% wound healing at 12 months follow-up). When including indirect revascularizations without visible collaterals,

Anatomically, the venous drainage follows the arterial perfusion of the angiosomes [23] and Alexandriescu used the term venosome, when reporting the results of surgical deep calf vein arterialization. In a series of 26 limbs in 25 diabetic patients with very advanced below the knee occlusive disease, a PTFE bypass was made between an arterial inflow and a deep

indirect revascularization may be inadequate for the healing of infected wounds.

it is probably biased by the general learning curve of the group.

group (p=0.002). The number of patients was, however, not reported.

only 73% of the wounds had healed after 12 months (p=0.008).

is, however, limited.

432 Artery Bypass

**6.1. The influence of collaterals**

**6.2. The significance of venosomes**

The concept of angiosome-directed revascularization is, theoretically, attractive and in ac‐ cordance with pathophysiological knowledge. It is also in line with experience from coro‐ nary bypass surgery, where reperfusion through collaterals does not provide a similar freedom from cardiac events as that provided by complete direct revascularization of all the diseased vascular territoria [2].

It is well established that healing of an ishemic pedal wound is more effectively ach‐ ieved when pulsatile arterial blood flow is established across the ankle and it seems logi‐ cal to expect that this effect is larger when the pulsatile flow is provided all the way to the site of the injury.

As suggested by the above mentioned papers, the effect of direct revascularization may es‐ pecially be relevant in the settings of end stage renal failure, infected wounds, endovascular rather than surgical repair, and in cases where collaterals are absent.

The angiosome concept represents a novel approach to improving the therapy of critical limb ischemia. It may potentially provide the rationale not only for the choice of target ar‐ tery. It may also influence the indications for endovascular or open repair according to which target artery is accessible by which method.

Although the evidence in favour of an angiosome directed treatment is mounting fast, it is, however, still circumstantial. All of the studies comparing the results of direct and indirect revascularization are retrospective and, thus, biased by heterogeneity in patient selection. More often than not, the angiosome specific artery will also be the most diseased artery and the ability to recanalize this vessel will most probably select the least atherosclerotic patients to the "direct revascularization" group. It is also likely that the advocates of an angiosomedirected revascularization strategy would attempt direct revascularization first and only perform indirect revascularization if this attempt was unsuccessful. Regardless of any retro‐ spective matching of the groups this would lead to patients with extensive distal atheroscle‐ rosis to be placed in the indirect revascularization groups, thus biasing the comparisons in favour of the angiosome specific approach. The differences in healing rate and limb salvage between groups may, therefore, merely reflect preoperative differences in the extent of oc‐ clusive disease. It is possible that this is what is reflected in the lack of statistically signifi‐ cant differences after propensity scoring in the study by Azuma [13].

As highlighted in the study by Varela, the presence or absence of collaterals merit further investigation [22]. For this purpose, the Doppler method described by Attinger [7] seems to be a good and non-invasive technique.

As evidence stands at the moment, there is some, although limited, evidence that when there is a choice of target artery for revascularization, preference should be given to the ar‐ tery directly feeding the wound´s angiosome. Specific analysis, based on prospectively col‐ lected data of homogeneous cohorts of patients are needed. Unbiased evidence will only be achievable by performing a prospective, randomized controlled trial with a blinded endpoint assessment.

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[11] Nagase T, Sanada H, Takehara K, Oe M, Iizaka S, Ohashi Y, Oba M, Kadowaki T, Na‐ kagami G. Variations of planatar thermographic patterns in normal controls and non-ulcer diabetic patients: Novel classification using angiosome concept. Journal of

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