Direct Revascularization with the Angiosome Concept for Lower Limb Ischemia

The angiosome concept provides practical information regarding the vascular anatomy of reconstructive and vascular surgery for the treatment of peripheral arterial occlusive disease and, particularly, critical lower limb ischemia. The aim of the study was to confirm the efficacy of direct revascularization with the angiosome concept (DR) for lower limb ischemia. Complementary manual searches were performed through the Pubmed, Cochrane Library, and EMBASE databases. We searched all randomized and nonrandomized studies (NRSs) comparing DR with indirect revascularization (IR) (without the angiosome concept) for lower limb ischemia. Only 9 nonrandomized controlled retrospective cohort studies were found and included. Trials published in any language were included. Primary endpoints were time to limb amputation and time to wound healing. Data extraction and trial quality assessment were performed by two authors independently. A third author was consulted for disagreements settlement and quality assurance. Five NRSs involving 779 lower limbs revealed that DR significantly improved the overall survival of limbs (hazard ratio [HR] 0.61; 95% confidence interval [CI]=0.46-0.80; P<0.001; I 2 =0%). In addition, DR significantly improved time to wound healing (HR 1.38; 95% CI=1.13-1.69; P=0.002; I 2 =0%, in 5 studies including 605 limbs). All included studies were retrospective comparative studies, and no consensus was obtained in describing wound conditions in the included studies. Our results suggested that treatment of lower limb ischemia using DR is more effective in salvaging limbs and healing wounds than IR is. Additional randomized controlled studies are necessary to confirm these results.