Jain Institute of Vascular Sciences, Bhagwan Mahavir Jain Hospital, NCR, India.
J Vasc Surg. 2013 Jan;57(1):44-9. doi: 10.1016/j.jvs.2012.07.042. Epub 2012 Oct 9.
Blood supply to the foot is from the posterior tibial, anterior tibial, and the peroneal arteries. Ischemic ulceration of the foot is the most common cause for major amputations in vascular surgical patients. It can be presumed that revascularization of the artery directly supplying the ischemic angiosome may be superior to indirect revascularization of the concerned ischemic angiosome.
This was a prospective study of 64 patients with continuous single crural vessel runoff to the foot presenting with critical limb ischemia from January 2007 to September 2008. Direct revascularization (DR) of the ischemic angiosome was performed in 61% (n=39), indirect revascularization (IR) in 39% (n=25). Open surgery was performed in 60.9% and endovascular interventions in 39.1%. All patients were evaluated for the status of the wound and limb salvage at 1, 3, and 6 months. The study end points were major amputation or death, limb salvage, and wound epithelialization at 6 months.
In the study, 81.2% of patients had forefoot ischemia, 17.2% had ischemic heel, whereas 1.6% had midfoot nonhealing ischemic ulceration. The runoff involved the anterior tibial artery in 42.2% (27/64), posterior tibial artery in 34.4% (22/64), and the peroneal artery in 23.4% (15/64). All patients were followed at 1, 3, and 6 months postoperatively for ulcer healing, major amputation, or death. At the end of 6 months, nine patients expired, and six were lost to follow-up. Of 49 patients who completed 6 months, nine underwent major amputation, and 40 had limb salvage. Ulcer healing at 1, 3, and 6 months for DR vs IR were 7.9% vs 5%, 57.6% vs 12.5%, and 96.4% vs 83.3%, respectively. This difference in the rates of ulcer healing between the DR and IR groups was statistically significant (P=.021). The limb salvage in the DR group (84%) and IR group (75%) was not statistically significant (P=.06). The mortality was 10.2% for DR and 20% for IR at 6 months.
To attain better ulcer healing rates combined with higher limb salvage, direct revascularization of the ischemic angiosome should be considered whenever possible. Revascularization should not be denied to patients with indirect perfusion of the ischemic angiosome as acceptable rates of limb salvage are obtained.
足部的血液供应来自胫后动脉、胫前动脉和腓动脉。足部缺血性溃疡是血管外科患者大截肢的最常见原因。可以推测，直接重建供应缺血血管单元的动脉可能优于间接重建相关缺血血管单元。
这是一项前瞻性研究，纳入了 2007 年 1 月至 2008 年 9 月期间因连续单肢血管向足部供应而出现严重肢体缺血的 64 例患者。61%（n=39）行缺血血管单元直接血运重建（DR），39%（n=25）行间接血运重建（IR）。60.9%的患者接受开放手术，39.1%的患者接受血管内介入治疗。所有患者在 1、3 和 6 个月时均评估伤口和肢体存活情况。研究终点为 6 个月时的大截肢或死亡、肢体存活和伤口上皮化。
研究中，81.2%的患者有前足缺血，17.2%有缺血性足跟，而 1.6%有中足非愈合性缺血性溃疡。前向血流累及胫前动脉 42.2%（27/64），胫后动脉 34.4%（22/64），腓动脉 23.4%（15/64）。所有患者均在术后 1、3 和 6 个月随访溃疡愈合、大截肢或死亡情况。在 6 个月时，9 名患者死亡，6 名患者失访。在完成 6 个月随访的 49 名患者中，9 名患者接受了大截肢，40 名患者肢体存活。DR 组和 IR 组的溃疡愈合率在 1、3 和 6 个月时分别为 7.9%和 5%、57.6%和 12.5%、96.4%和 83.3%。DR 组和 IR 组的溃疡愈合率差异有统计学意义（P=.021）。DR 组（84%）和 IR 组（75%）的肢体存活率差异无统计学意义（P=.06）。DR 组和 IR 组的 6 个月死亡率分别为 10.2%和 20%。
为了获得更好的溃疡愈合率和更高的肢体存活率，只要有可能，就应考虑对缺血血管单元进行直接血运重建。不应拒绝对间接供应缺血血管单元的患者进行血运重建，因为这样可以获得可接受的肢体存活率。
