Impact of angiosome targeted femorodistal bypass surgery on healing rate and outcome in chronic limb threatening ischaemia

Objective: In the presence of long lesions, in patients with chronic limb threatening ischaemia, a femorodistal bypass is often the only option to avoid major amputation. This study investigated whether targeted bypass to the affected angiosome, according to the angiosome concept definition of direct (DR) and indirect revascularisation (IR), has an impact on wound healing, major amputation rate, and mortality. Methods: A retrospective analysis was performed at Ghent University Hospital of 201 non-healing ischaemic wounds (Rutherford categories 5 and 6) requiring femorodistal bypass surgery in 177 patients (61% male, median age 69 years) with a follow up of 36 months. For every patient, the site of the ulcer, the type of bypass, and material were identified. Based on ulcer location and distal anastomosis, the legs were divided into DR and IR. Kaplan-Meier univariable analysis was used to estimate cumulative ulcer healing, leg salvage, survival, and patency. Results: DR was performed in 103 legs (51%) and IR in 98 legs (49%), with no difference in comorbidity. The mean wound healing time was seven months. DR did not lead to a higher healing rate. The fastest healing rate was obtained when opting for a DR with an autologous greater saphenous vein (GSV; 90% at 12 months). Cryopreserved allografts also yielded good results, especially for wound healing after IR (85% at 12 months). Major amputation was performed in 28.5% after IR vs. 17.3% after DR (p = .071). There was no difference in mortality rate (36.8% [DR] vs. 41.3% [IR]) (p = .088). Autologous GSV had a longer primary patency, primary assisted patency, and secondary patency (26, 34, and 38 months, respectively) than cryopreserved GSV (12.5, 18, and 24 months, respectively) (p = .002, p = .003, and p = .018, respectively), with no difference between DR and IR. Conclusion: Direct or indirect revascularisation performed according to the angiosome concept definition yields similar results with regard to healing rates, limb salvage, and mortality