The role of foot collateral vessels on angiosome-oriented revascularization

For many years, it has been generally accepted that distal vein bypass revascularization performed to the less diseased angiographic tibial vessel was the most effective treatment for critical limb ischemia (CLI) and tissue loss, as long as a direct line of blood flow to the foot was obtained. The main objective of the revascularization procedure is to obtain sufficient foot perfusion to ensure ischemic ulcer healing, since delayed healing increases the risk of limb loss (1-3). However, the meteoric endovascular therapy technology developments seen in the last decades have radically changed this paradigm. Nowadays, distal vein bypass still stands as the gold standard treatment for CLI revascularization due to its greater durability and its proven effectiveness. Nevertheless, endovascular tibial procedures represent an attractive option for CLI patients, usually frail elderly individuals with diabetes mellitus and severe comorbidities, because of its lower procedure-related complications when compared with bypass. Furthermore, according to several studies, tibial endovascular procedures could provide similar clinical outcomes as open surgical reconstruction surgery (4,5). For these reasons, many vascular surgeons have implemented the endovascular therapy as first line of treatment for CLI.