Evaluation of angiosome-targeted infrapopliteal endovascular revascularization in critical diabetic limb ischemia

Objective To evaluate the rates of wound healing and limb preservation following angiosome-targeted infrapopliteal endovascular revascularization in the treatment of diabetic limb ischemia.Methods We performed a retrospective analysis of data gathered from 102 infrapopliteal angioplasty cases (60 males and 42 females; mean age, 72 ± 11 years) with Fontaine IV ischemia (ankle-brachial index, ABI: 0.16 ± 0.06). Forty-seven angioplasties were performed based on the angiosome concept (direct revascularization, DR), while 55 did not incorporate the angiosome concept (indirect revascularization, IR). The curative effects of angioplasty were assessed by postoperative determinations of ABI performed every 3 months during clinical follow-up visits conducted to assess healing of the ischemic wound. Amputation and death events were recorded throughout the study.Results All 102 patients were successfully revascularized without complications, and during a mean follow-up period of 18 ± 11 months, the mean postoperative ABI improved to 0.84 ± 0.10. The postoperative 6 and 12 month healing rates in the DR group were 85.1% and 93.5%, respectively, while the limb-salvage rates were 100% and 93.5%, respectively. The postoperative 6 and 12 month healing rates in the IR group were 60% and 76.4%, respectively, while the limb-salvage rates were 90.1%, and 85.5%, respectively.Conclusion Angiosome-based Infrapopliteal angioplasty was associated with better wound healing and higher rates of limb salvage in cases of critical diabetic foot ischemia. Revascularization should be provided to patients who have undergone indirect perfusion of the ischemic angiosome, as acceptable rates of limb salvage are obtained.     

Topographical anatomy of the transverse facial artery

The transverse facial artery (TFA) is found in the lateral face and supplies the parotid gland and duct, facial nerve, facial muscles, and skin. To better understand the cutaneous vascularization of the lateral face and to better characterize the topography and other anatomical features of the TFA, microsurgical dissection was performed in 44 cadavers. The number of TFAs present ranged from one to three, and a single TFA was most common (70.5%). The TFA originated from the superficial temporal artery at or above the level of crossing by the temporofacial trunk of the facial nerve in the parotid gland (57.6%). The TFA divided into superior and inferior trunks in the gland, and continued as emerging branch. The superior emerging branch emerged from the gland superior to the parotid duct and divided into many branches. It supplied the malar area, crossed the parotid duct, terminated as perforator, vasa nervorum, or artery to the parotid duct or muscle. The inferior trunk in 72.5% continued as emerging branch instead of terminating in the gland. TFAs were classified into four types; the most common type was Type A in which the superior and inferior emerging branches and the duct‐crossing branch were present. The mean number of perforators to the superficial cutaneous layer was 1.9. Most perforators extended from the superior emerging branches (77.9%). The most common perforating site was below the duct on the anterior third of the masseter muscle. In two cases, the TFA formed an anastomosis with the facial artery. Clin. Anat. 23:168–178, 2010. © 2009 Wiley‐Liss, Inc.     

动脉跨区供血的头皮瓣一期修复肿瘤切除与创伤后的大面积头皮缺损

目的探讨大面积头皮缺损的一期修复方法。方法应用颞浅动脉跨区供血的头皮瓣、眶上动脉-枕动脉双蒂跨区供血的头皮瓣,修复伴有颅骨缺失的大面积头皮缺损5例。结果5例动脉跨区供血的头皮瓣全部成活,创面均一期修复,效果满意。结论应用单支或双支头皮动脉跨区供血的大型头皮瓣,可以安全地一期修复大面积头皮缺损。     

Three‐dimensional visualization of the cutaneous angiosome using angiography

The purpose of this study was to establish the three‐dimensional (3D) architecture of the cutaneous angiosome for assessment and design of the perforator flaps. Two fresh cadavers were injected with carboxymethyl cellulose (CMC)/lead oxide and computed tomography (CT) scanned before and after the injection. The various parts of the cutaneous and subcutaneous tissue derived from one of the injected cadavers were also CT scanned. Three‐dimensional reconstruction of the cutaneous angiosome and the two flap designs were performed using Materialise's Interactive Medical Image Control System (MIMICS). Both the reconstructed cutaneous angiosomes and the digital flaps can be displayed independently or in conjunction with bones, source arteries, and skin. The 3D architecture of the cutaneous angiosome ensures clear display of the spatial location, distribution range, and anastomoses relationship of the cutaneous perforators. In addition, the caliber, length, and position of a particular source artery are illustrated in the exact spatial location. As a result, the technique provides visualization of the general area and the expandable direction of a respective flap. This technique has the potential to play an important role in assessing perforator blood supply territory and in the design of new flaps.Clin. Anat. 2013. © 2012 Wiley Periodicals, Inc.     

糖尿病足下肢血运重建技术与治疗策略

随着糖尿病患病率逐年升高,患有糖尿病的慢性威胁性肢体缺血（chronic limb-threatening ischemia,CLTI的发病率也呈上升趋势。在多达50%的糖尿病足溃疡患者中可以观察到外周动脉疾病（peripheral arterial disease,PAD）的症状或体征,同时PAD也是伤口愈合不良和截肢的危险因素。治疗患有糖尿病的PAD患者更困难,因为其更易发生长节段闭塞、严重钙化且更多累及远端。因此,针对这些患者的治疗策略与其他PAD患者应该有所区分。最近研究强调了糖尿病足患者的不同血运重建方法、治疗技术、设备及其疗效,这些治疗方式与技术有望缓解缺血性疼痛,治愈足部溃疡,降低截肢率和缩小截肢范围,并改善患者的功能和生活质量。本文对糖尿病足患者下肢血运重建不同治疗方式临床数据进行分析,讨论不同方式的优点,详细介绍糖尿病足下肢血运重建策略,还关注了可用于糖尿病足下肢血运重建的最新治疗技术和设备,旨在提供较为全面的糖尿病足下肢血运重建研究进展。     

Diabetic Foot Disease: Emerging Technologies: Morphological Pattern Classification System for Plantar Thermography of Patients with Diabetes

Background

A plantar temperature distribution can be obtained by thermography; however, the advantage has not been effectively utilized in the past. We previously proposed a classification method based on the angiosome concept, but the method was insufficient because it was too subjective and complicated for clinicians. In this study, we propose a new classification system of plantar forepart thermographic patterns using an image segmentation technique.

Methods

A cross-sectional observational study was conducted including 32 healthy volunteers and 129 patients with diabetes mellitus (DM). Individual thermographic variations and trends were evaluated. A comparison was conducted between the patterns obtained by our previous angiosome-based research and the patterns found by the new classification system.

Results

The system objectively found wider variations of the plantar forepart thermographic patterns in the patients with DM compared with those in the control subjects. In patients with DM, the system showed that the whole-high pattern was most frequent (46%), followed by the butterfly pattern (12%). In the control group, the butterfly pattern was most frequent (44%), followed by the whole-high pattern (19%). Both ankle and toe brachial indices were higher in feet with high temperature area in the inner side of the plantar.

Conclusions

Thermographic patterns found by the new computer-based system were similar to those obtained in our previous subjective work. The classification system found forefoot-low pattern and tiptoe-low pattern objectively. The system based on infrared thermography will be a screening tool to assess circulatory status in daily foot care of patients with DM.     

Endovascular Techniques In Limb Salvage: Infrapopliteal Angioplasty

Critical limb ischemia (CLI) results from inadequate blood flow to supply and sustain the metabolic needs of resting muscle and tissue. Infragenicular atherosclerosis is the most common cause of CLI, and it is more likely to develop when multilevel or diffuse arterial disease coincides with compromised run-off to the foot. Reports of good technical and clinical outcomes have advanced the endovascular treatment options, which have gained a growing acceptance as the primary therapeutic strategy for CLI, especially in patients with significant risk factors for open surgical bypass. In fact, endovascular recanalization of below-the-knee arteries has proven to be feasible and safe, reduce the need for amputation, and improve wound healing. The distribution of various vascular territories or angiosomes in the foot has been recognized, and it appears advantageous to revascularize the artery supplying the territory directly associated with tissue loss. In addition, the targeted application and local delivery of drugs using drug-coated balloons (DCB) during angioplasty has the potential to improve patency rates compared to balloon angioplasty alone.