Direct Endovascular Revascularization Based on the Angiosome Model Reduces Risk of Major Amputations and Increases Life Expectancy in Type 2 Diabetic Patients with Critical Limb Ischemia and Foot Ulceration

Background: We evaluated whether direct or indirect endovascular revascularization, based on angiosome model (AM), affects outcomes in type 2 diabetes (T2DM) and critical limb ischemia (CLI). Methods: From 2010 to 2015, 603 T2DM were admitted for CLI and submitted to endovascular revascularization. Among these, 314 (52%) underwent a direct and 123 (20%) an indirect revascularization, depending on whether the flow to the artery directly feeding the site of ulceration, according to the AM, whereas 166 patients (28%) were judged not revascularizable. Outcomes were: healing (HR), major amputation (MA) and mortality rates (MR), respectively. Results: An overall HR of 62.5% was observed: patients who did not receive PTA presented a HR of 58.4% (p< 0.02 vs revascularized patients). An higher HR was observed in the direct group versus indirect one (82.4% vs 50.4%. p<0.001). MA rate was significantly higher in indirect group than in direct one (9.2% vs 3.2%. p<0.05). MR was 21.6% and higher in indirect revascularization (24% vs 14% in direct group. p<0.05). Conclusions: Our data show that direct revascularization of arteries supplying the diabetic foot ulcers site by means of AM is associated with higher healing rate and lower risk of amputation and death as compared to indirect procedure. These results support use of AM in T2DM with CLI.