Defining Anatomy and Blood Flow in the Threatened Limb
Rising to the Challenge With Noninvasive Imaging
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See Article by Alvelo et al
Critical limb ischemia (CLI) is a large and growing diagnostic and therapeutic challenge, reflecting the limb-threatening end stage of progressive lower-extremity arterial disease.1 The factors that ultimately tip the balance between required and available tissue perfusion are not fully understood, but both arterial inflow and local microcirculatory components are felt to play a role.2 Aggressive risk factor modification, antiplatelet therapy, and structured exercise programs play an important role in the patient with lower-extremity arterial disease, but as symptoms progress to CLI, local interventions become necessary. It is widely accepted that arterial revascularization is the single most effective therapy to promote ulcer healing, relieve rest pain, and prevent limb amputation, such that ≤90% of patients with CLI will undergo a revascularization procedure.1 In recent years, huge technical strides have been made in the approach to the femoral, popliteal, and infrapopliteal arteries, spearheaded by advances in endovascular therapy.3 Balloon angioplasty, atherectomy, or stenting can often reestablish flow to tissues at risk, sufficient to promote ulcer healing and help fight infection. In this context, debate is ongoing about the benefits of targeting the specific leg artery that, in health, is responsible for providing flow to the ulcerated skin or gangrenous tissues. The association between a specific leg artery and the tissues it supplies has been formalized in the angiosome model originally espoused by Taylor and Palmer.4 An angiosome identifies …