Effect of direct or indirect revascularization on clinical outcomes in acute and chronic process in endovascular treated below-the-knee lesions based on angiosome concept

INTRODUCTION AND AIM: In our study, we aimed to investigate the effect of direct or indirect revascularization on major amputation, minor amputation and wound healing in endovascular intervention based on angiosome concept in patients with chronic extremity-threatening ischemia. MATERIALS AND METHODS: A total of 121 patients were included in the study. During the follow-up period, death occurred in 3 patients, successful revascularization could not achieved in 29 patients, or the procedure could not be performed due to the lack of distal arterial beds. The remaining patients were divided into direct revascularization (DR) (n=59) and indirect revascularization (IR) (n=30) groups by whether feeding artery flow to the site of ulceration or gangrene was successfully achieved, based on the angiosome concept. The patients were followed for three months in terms of major and minor amputations and wound healing. RESULTS: 100 (84.7%) of the patients were male and the mean age was 63.9 ± 11.6 years. Ninety patients (76.3%) had diabetes mellitus, 71 (60.2%) essential hypertension, 58 (49.2%) coronary artery disease, 97 (82.2%) hyperlipidemia, 52 (44.1%) chronic kidney disease. Thirty-seven (31.4%) of the patients were active smokers, and 61 (51.7%) of the patients were ex-smokers. Rutherford class was 5 in 89 (75.4%) patients and Rutherford class was 6 in 29 (24.6%) patients. ABI values before the procedure were 0.74 ± 0.25, and NIRS values were 49.3 ± 11.3 rSO2. Successful intervention were performed to ATA in 65 (73.0%) of 89 patients, PTA in 40 (44.9%), and peroneal artery in 19 (21.3%) of 89 patients who underwent successful revascularization. During follow-up, the major amputation rate was lower in the DR group compared to the IR group (10.2% vs 30%, P=0.018), the minor amputation rate was similar (23.7% vs 23.3%, p=0.967), and wound healing was better in the DR group (%) 61 vs 36.7%, p=0.030). CONCLUSION: Percutaneous transluminal angioplasty based on the angiosome concept is an effective treatment option for isolated below-knee lesions in the mid-term to prevent major amputation and improve wound healing. Because of its clinically better outcomes, direct revascularization should be tried first as treatment modality.