Are We Misrepresenting SFA Stenting? High Rates of Restenosis and Limb Loss Are Seen in Patients with Chronic Wounds
A figure illustrating the pertinent vascular and muscular anatomy of the lower extremity relevant for angiosome directed revascularization. Created for Dr. Cameron Akbari, Department of Vascular Surgery, MedStar Georgetown University Hospital Center. Presented at the Eastern Vascular Society 36th Annual Meeting; Philadelphia, PA; September 2022.
(A) Anterior view of vascular anatomy CFA: Common Femoral Artery; SFA: superficial femoral artery (SFA1/2/3: proximal, middle, distal 3rd); PA: popliteal artery (PA1/2/3: proximal, middle, distal 3rd); ATA: proximal 3 cm of the anterior tibial artery (ATA1/2/3: proximal, middle, distal 3rd); PEA: proximal 5 cm of the peroneal artery (PEA1/2/3: proximal, middle, distal 3rd); PTA: proximal 5 cm of the posterior tibial artery (PTA1/2/3: proximal, middle, distal 3rd); TPT: tibial-peroneal trunk. Proximal segment (SFA, PFA, and PA), distal segment (TPT, ATA 1/2/3, PEA 1/2/3, and PTA 1/2/3), pedal segment (DPA, MPA, LPA). MPA and LPA were not measured on angiography; labeling is provided in SDC 2. The proximal disease was defined as the involvement of the Common Femoral Artery (CFA), Superficial Femoral Artery (SFA 1/2/3 proximal, middle, distal 3rd), popliteal artery (PA1/2/3: proximal, middle, distal 3rd). The distal disease was defined as the involvement of the ATA: proximal 3 cm of the anterior tibial artery (ATA1/2/3: proximal, middle, distal 3rd); PEA: proximal 5 cm of the peroneal artery (PEA1/2/3: proximal, middle, distal 3rd); PTA: proximal 5 cm of the posterior tibial artery (PTA1/2/3: proximal, middle, distal 3rd); TPT: tibial-peroneal trunk. There were no significant differences between the lesion lengths between limb salvage and amputation cohorts (P = 0.645). (B) Distribution of lesions in patient pre-procedure angiograms. Percentages represent the proportion of individuals with a lesion present in the corresponding vascular segment. For the overall cohort, lesions traversed the CFA (5), SFA1 (33), SFA2 (36), SFA3 (41), PA1 (34), PA2 (25), and PA3 (20); We observed stenosis or occlusive disease of the AT (38) and PT (40). All % represents the ratio of lesions present per patient of the respective subgroup. The color denotes the frequency of occurrence for each anatomical segment, with a deeper red signifying a higher proportion of patients.
Vascular Supply, Angiosomes, and Muscles of the Lower Extremity. Visual depiction of the segmented arterial supply of the lower extremity, corresponding 21 cutaneous vascular territories (angiosomes), and lower extremity muscles. Colors correspond to the named vessel for the cutaneous angiosomes and dominant blood supply to the muscles. Illustrations reflect (A) an anterior view of the anatomy of the arteries, (B) an anterior view of angiosomes and muscles, and (C) a posterior view of angiosomes and muscles of the lower extremity. Named vessels have a corresponding angiosome pictured in color consistent with the vessel (A). Acronyms and associated muscles include the following list, due to the presence of anastomotic connections and dual blood supply, the colors of the muscles reflect the shade of the vessel which composes the dominant blood supply. (1) gluteal region: SGA: superior gluteal artery, IGA: inferior gluteal artery, (2) hip and thigh: SCIA: superficial circumflex iliac artery, FA: femoral artery (further segmented into the CFA (common), SFA1/2/3 (superficial, proximal, middle, and distal)), LCFA: lateral circumflex femoral artery, MCFA: medial circumflex femoral artery. (3) knee and leg: DGA: medial genicular artery, LSGA: lateral superior genicular artery, LIGA: lateral inferior genicular artery, MSGA: medial superior genicular artery, MIGA: medial superior genicular artery, PA: popliteal artery, PT: posterior tibial artery (1/2/3: proximal, middle, distal), ATA: anterior tibial artery (1/2/3: proximal, middle, distal), PEA: peroneal artery (4) ankle and foot: MCA: medial calcaneal artery, LCA: lateral calcaneal artery, LPA: lateral plantar artery, MPA: medial plantar artery, DPA: dorsalis pedis artery. Illustrations were adapted from Attinger, C. E. et al. (2006). "Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization." Plast Reconstr Surg 117(7 Suppl): 261S-293S. Drake, R. L., Ph.D., FAAA, et al. (2021). Gray's Atlas of Anatomy, Third Edition, Elsevier. Wong, A. and S. Morris (2020). Vascular Anatomy of the Lower Extremity: A Practical Guide to Vascular Territories, Perforators, and Selection of Recipient Vessels. Lower Extremity Reconstruction: A Practical Guide. New York, Thieme. 1. Neligan, P. C., et al. (2012). Comprehensive lower extremity anatomy. Plastic Surgery E-Book: 6 - Volume Set: Expert Consult - Online, Elsevier Health Sciences, 2012.)