WIfI Classification Versus Angiosome Concept: A Change in the Infrapopliteal Angioplasties Paradigm.

OBJECTIVE: The objective of this study was to determine whether the angiosome concept and WIfI classification in patients undergoing endovascular treatment is associated with the limb salvage rate and wound healing rate in patients with critical limb ischemia(CLI). METHODS: This was a retrospective, consecutive cohort study of CLI patients who underwent infrapopliteal angioplasty at the Vascular and Endovascular Surgery Service of the Hospital do Servidor Público Estadual, São Paulo, between January 2013 and January 2019. The primary outcome variable was the limb salvage rate and wound healing rate. The secondary outcome variables were patency, survival, time free from reintervention, and operative mortality rate. RESULTS: Overall, 95 infrapopliteal endovascular procedures were performed in 95 patients. The initial technical success rate was 100%. The mean ± standard deviation outpatient follow-up time was 775 ± 107.5 days. The analyses were performed at 360 days for wound healing rate and 720 days for limb salvage rates, overall survival, and time freedom from reintervention. According to the angiosome concept, there were 54 patients (56.8%) classified in the direct group and 41 patients (43.2%) in the indirect group. Regarding the WIfI classification subanalysis, there were 22 patients WIfI 0-1 (23.2%) and 73 patients WIfI 2-3 (76.8%). Furthermore, the indirect group had a higher ulcer healing rate than the direct group; however, it was not statistically significant (82.9%; 66.7%%, respectively, P = 0.059). However, the time to heal the ulcer was faster in the WIfI 0-1 groups than WIfI 2-3 groups (164.82 days versus 251,48; P = 0.017). The limb salvage rates at 720 days were similar among indirect and direct Groups (92.6% and 85.4%, P = 0.79). Likewise, the freedom from reintervention rates at 720 days were also similar in Indirect and direct groups (74.6% and 64%, P = 0.23). The survival rates at 720 days were similar in both indirect and direct groups (86.8 and 85.6%, respectively; P = 0.82). The amputation free survival rate at 720 days by the Kaplan-Meier method was 91.3% in the indirect group and 85.9% in the direct group, but with no statistical significance between the groups (P = 0.37) CONCLUSIONS: This study concluded that, in endovascular treatment, the angiosome concept is no longer important to limb salvage rates, nor ulcer/wound healing rates. Moreover, the WIfI classification 0-1 is associated with faster and higher wound/ulcer healing rates than WIfI classification 2-3.

Vein bypasses to branches of pedal arteries.

OBJECTIVE: We report a retrospective analysis of our experience in bypass vein graft surgery to lateral tarsal, medial plantar, and lateral plantar arteries for treatment of critical limb ischemia (CLI). METHODS: Between January 1991 and February 2010, we performed 137 inframalleolar bypass graft surgeries; of these, 25 (18%) were conducted using foot branch arteries for distal implant. All patients were treated for CLI and most had extensive infrapopliteal atherosclerotic disease (TransAtlantic Inter-Society Consensus D). Mean follow-up was 46.32 months (range, 0-144 months). Main end points analyzed were cumulative patency, limb salvage, and survival. Statistic analysis of all end points was performed using Kaplan-Meier survival curves. RESULTS: There was a predominance of men (64%), and the group mean age was 66.3 years. Diabetes mellitus was the main associated disease. Eighty percent of ulcers or gangrene were restricted to the midfoot (Rutherford V CLI classification). There was a predominance of short-length grafts using the great saphenous vein as the main conduit (72%). The medial plantar artery was the main outflow artery (52%). Early graft occlusion occurred in four patients (primary failure rate, 16%). Secondary patency at 1 and 3 years was 49% and 36.8%, respectively, and limb salvage was 81.7% and 69%, respectively. Nine major amputations occurred, and 10 other minor amputations were necessary. Survival rate at 3 years was 65.4%, and 67% of patients maintained ambulation. Surgical mortality was 8%. No condition was associated with worse results with regard to secondary patency, limb salvage, or survival. CONCLUSIONS: Long-term results for developed foot branch bypass demonstrated good results for limb salvage, and it is an acceptable surgery for patients with extensive atherosclerotic disease.

Bilateral external iliac artery aneurysm in a young man.

Most iliac artery aneurysms occur in association with aortic aneurysms. Isolated aneurysms of the iliac arteries are uncommon, and those of the external iliac arteries are even more rare. In the present report, we have presented the case of a bilateral external iliac artery aneurysm in a young man.