predictors of wound healing: direct angiosome...
TRANSCRIPT
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PNEC 2019
Predictors of Wound
Healing: Direct Angiosome
Perfusion vs. WIfIChristopher J. Abularrage, MD, DFSVS, FACSThe Bertram M. Bernheim Associate Professor of Surgery
Division of Vascular Surgery and Endovascular Therapy
The Johns Hopkins Hospital
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DISCLOSUREChristopher J. Abularrage, MD
• No relevant financial relationship reported
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Diabetic PADAngiosomes
• Angiosomes
• Concept defined by Ian Taylor in 1987
• Divides body into 3D anatomic units supplied by specific arteries
• Five units of the foot
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Case #111/2015
• 61 year old
• PMH: DM, ESRD, CABG
• PSH: Left BKA (5/14), Right TMA (6/14),
• Right heel ulcer (7/14); Failed Apligraf
• Right SFA stent & Pop→AT stent
• Right lateral malleolar ulcer (7/15)
• ISR s/p repeat POBA (8/15)
• Failure to improve, recommended BKA
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Case #1Bone scan + osteo calcaneus and fibula
PVR’s pulsatile
Right heel Right lateral malleolus
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Case #112/2015 S/p debridement and fibular Integra
Right heel Right lateral malleolus
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Case #11/2016 Failure of fibular Integra
Right heel Right lateral malleolus
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Case #11/2016 Angio
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Case #11/2016 Angio
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Case #11/2016
• Vein mapping excellent
• Stress Test→ +reversible ischemia
• Cardiac Cath→ Unreconstructable
disease distal to patent grafts
• Trial of HBO
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Case #12/2016
Right heel Right lateral malleolus
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Case #12/2016
4mm POBAPre
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Case #13/2016 S/p Heel STSG & fibular Integra
Right heel Right lateral malleolus
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Case #16/2016 S/p Heel STSG & fibular Integra
Right heel Right lateral malleolus
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Case #18/2016
Right lateral malleolus
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Case #18/2016 (6mo s/p TP Trunk POBA)
4mm
PredilBuddy wire
4x38mm DES
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Case #18/2016
Completion Angio
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Case #114 mo after initial presentation
9/2016 1/2017
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Diabetic PADAngiosomes
• 121 direct vs. 129 indirect limbs
• All endovascular interventions
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Diabetic PADAngiosomes
P<.001
Soderstrom M et al. J Vasc Surg. 2013;57:427-35
Propensity Score
Analysis
1. Adjusted for pre-tx
variables
2. In-line revascHR 1.97, 95%CI 1.34-2.90;
P=.001
Conclusion
Endo adequate if inline
flow acheived
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Definitions
• Direct Perfusion/Revascularization
• Open line from aorta to the artery supplying the wound angiosome (Lida)
• Heel and forefoot are PT (Alexandrescu)
• The angiosome artery revascularizedmatches that of the foot loss (Attinger)
• Little consensus when wounds span more than one angiosome
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Open vs. Endo
What about the wound?
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The WIfI Classification
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The WIfI ClassificationValidation
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The WIfI Classification
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Definitions
• Compare predictive ability of WIfI classification vs
direct angiosome perfusion for wound healing
• Direct Angiosome Perfusion
– Any artery supplying the angiosome was patent or
revascularized
• Pedal arch patency (Rutherford)
– 0: Widely patent with retrograde flow
– 1: Widely patent without retrograde flow
– 2: Diseased or partially occluded pedal arch
– 3: Little or no pedal arch
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Primary Outcome
• Wound Healing at one year
• Management
– Angiography with intent to perform
revascularization, preferentially direct
– Perfusion optimized if no direct options
– Debridement, local wound care, minor amputation
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Study Cohort
99 Patients
225 Wounds
• Mean age 63 years
• 62.6% male
• Hypertension 87.9%
• Dyslipidemia 65.7%
• Tobacco Use 54.5%
• Hgb A1c 8.4%
• Insulin 56.6%
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Wound Characteristics
May 25, 2019 72
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Results
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Results
P<.001
P=.89
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Results
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Results: Subanalysis
76
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Conclusion
• More severe WIfI wounds were 23% less
likely to heal at 1 year.
• While direct angiosome perfusion was not
related to wound healing, it may be important
for higher WIfI stage wounds.
• WIfI classification has broad applicability.
• WIfI stage should be standard inclusion in all
future angiosome studies.
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