Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 110-113

Applied features of perforasomes in the revascularization and reconstruction of chronic limb-threatening ischemia in the diabetic foot

1 Institute of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu, India
2 Department of Plastic and Faciomaxillary Surgery, Madras Medical College, Chennai, Tamil Nadu, India

Date of Submission04-Mar-2021
Date of Acceptance07-Apr-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
Balakrishnan Thalaivirithan Margabandu
Department of Plastic and Faciomaxillary Surgery, Madras Medical College, Chennai, Tamil Nadu
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_24_21

Rights and Permissions

Chronic limb-threatening ischemia in the diabetic foot is a spectrum disease characterized by the failure of wound healing and increased risk of amputation. The interspecialty consolidating services between the vascular and plastic surgeon with applied perforasome approaches both in the timely revascularization and early reconstruction culminate in the stable and shoeable foot or foot residuum.

Keywords: Chronic limb-threatening ischemia, diabetic foot syndrome, internal offloading of the diabetic foot, involved perforasomes-directed distal revascularization, perforasomes, perforasomes-based reconstruction

How to cite this article:
Paramasivam I, Margabandu BT, Palanisamy P, Christabel PM, Sritharan N, Janardhanan J. Applied features of perforasomes in the revascularization and reconstruction of chronic limb-threatening ischemia in the diabetic foot. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:110-3

How to cite this URL:
Paramasivam I, Margabandu BT, Palanisamy P, Christabel PM, Sritharan N, Janardhanan J. Applied features of perforasomes in the revascularization and reconstruction of chronic limb-threatening ischemia in the diabetic foot. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 May 25];8, Suppl S2:110-3. Available from:

  Introduction Top

Among various diabetic foot surgery disciplines, the management of chronic limb-threatening ischemia in the diabetic foot (DF-CLTI) is the one exacting the most integrating and consolidating interspecialty services of the vascular and plastic surgeons. The aim of this interaction is to salvage a functional foot.[1],[2],[3],[4] The revascularisation and reconstruction are in continuum. They are overlapping interventions culminating in the useful shoeable and stable foot or foot residuum for the diabetic patients. The continued and progressive understanding of cutaneous vascular anatomy[1],[2],[3],[4] largely facilitates all these advancements in the diabetic foot preservation surgery.

The first focused research on the cutaneous vascular supply started in the late 19th century by Carl Manchot and Salmon.[5],[6],[7] They named “the vaso-neuro-histo-surgical unit supplied by varying the number of perforator vessels arising from the single source vessel” as “anatomical cutaneous vascular territory.” They defined forty anatomical cutaneous vascular territories and 374 major perforators in the human body. Elaborating further on Manchot and Salmon's theory with modern gadgets on the source vessels Taylor et al.[8],[9],[10] introduced the terminology “angiosomes” in 1970s. They included the muscle and osseous tissues along with overlying skin supplied by the same source vessel and named these blocks of tissues as “Angiosomes.” The real revolution emerged in the concept of cutaneous vascular supply in 1980s when Isao Koshima et al. introduced “perforasomes.”[11],[12],[13],[14],[15],[16],[17],[18] The perforasome is now defined as “a vaso-neuro-osteo-histo surgical unit supplied by the single perforator vessels (containing single perforator artery, and one or two venae commitantes and also sometimes a cutaneous nerve) arising from the source vessel.”[1],[2],[19]

  Changing Pattern of Diabetic Foot Syndrome Top

In the last decade, several studies revealed that there was an increase in the prevalence of DF-CLTI.[20],[21],[22] The preliminary data from our institutional epidemiological study also reported an increase in the prevalence of DF-CLTI from 11.8% in 2012 to 13.5% in 2016 in our population. Several studies[23],[24],[25],[26] also reported an increase in the prevalence of lower extremity arterial disease in the diabetic population attributing to increased limb loss. DF-CLTI always occurs as a result of the combined effect of macroangiopathy and microangiopathy.[27],[28] The probable cause for this changing pattern of diabetic foot syndrome could be because of increasing prevalence and incidence of smoking, hypertension, and dyslipidemia in the diabetic population.[29] Burgeoning evidence is now available that the ischemic ulcers in the diabetic foot are the most common forerunners of amputation.[30],[31]

  DF-CLTI: A Conundrum for the Vascular and Plastic Surgeon Top

According to the global vascular guidelines (GVG)[32] and in our large understanding of diabetic crural ischemia population over the years “DF-CLTI is a broad spectrum disease characterized by severe, moderate, and mild ischemia which manifests as (1) varying degree of wound healing failure and (2) with increased risk of limb loss.”

  Why Perforasome Approach in the Revascularization and Reconsruction of DF-CLTI? Top

The pathogenesis and manifestation of the DF-CLTI itself follow the perforasomes pattern [Figure 1]. Hence, it is syllogistic to approach the DF-CLTI also by perforasomal approaches.[2] The present concept of early involved perforasomes-directed distal revascularization (IPDDR) should be achieved in DF-CLTI either by the endovascular therapy or by the open surgery.[2] This is achieved by the straight-line flow to the involved perforasomes with improved peripheral run off and “wound blush.”[33] In DF-CLTI, it has been elicited that the involvement of intercommunicating arteries between the axial vessels of the leg and foot is common and this envisages the IPDDR.[34] The indirect revascularization and the collaterals based peripheral run off in the DF-CLTI are now considered less than perfect procedures.[2] Armstrong et al.[35] and Margolis et al.[36] had shown in their study that critical ischemia of the lower extremity combined with infection was responsible for major limb loss. Several studies[37],[38],[39] have established that by dedicated multispecialty integrated approach by angiosome-directed revascularization and reconstructions of the DF-CLTI, a shoe able and stable foot or its residuum was possible. We have also established in our study that IPDDR could reduce the amputation rate of neuroischemic diabetic foot.[1] Effendi et al.[40] in their cases of very poor peripheral pedal run off, the foot was salvaged by the distal selective arterialization of selective venosomes of the foot. Gandini et al.[41] reported retrieval of the wound healing potential in “no option cases” with severely calcified posterior tibial artery in which a deliberate arteriovenous fistula was created with the plantar veins. The current GVG[42] points toward achieving the “target arterial pathway” to the involved perforasomes in the salvage of DF-CLTI.
Figure 1: A case of DCLTI showing the gangrene exclusively involving the medial plantar artery perforasomes (left and middle). Catheter angiogram showing poor peripheral run off involving the medial plantar artery territory (right). P2 GLASS (Global Limb Anatomical Staging System) category in the infra malleolar vessels

Click here to view

In addition to the vast advancements in IPDDR, it bestows the facilities for augmenting the distal target pedal source recipient vessel for enabling the microvascular anastomosis. This is the pinnacle of the interspecialty integration between the endovascular therapist and the plastic surgeon which initiates and facilitates the perforasomes oriented reconstruction of the DF-CLTI.

  Perforasomes-Oriented Diabetic Foot Preservation Surgery in DF-CLTI Top

Now the global consensus in the management of DF-CLTI is to salvage foot with all modalities possible and aim for shoeable and stable foot or residuum of foot. The second important aim, one should incorporate all adjuvant treatments such as internal offloading[1],[2],[3] as an integral part of reconstruction to prevent transfer lesions and recidivism. There are several factors such as Monckebergs sclerosis of infragenual vessels, edema, neuropathy, and infection that pose hurdles in the recognition of the DF-CLTI.[1],[2],[19] Sclerosed vessels in the infragenual region mask the ischemia by false high ankle brachial index. Edema and neuropathy blunts the inflammatory response in the ischemic foot and gives the false appearance of no florid infection. Bacterial infections pose more metabolic demand locally and aggravate ischemia in the diabetic foot in the face of fixed and restrained blood flow/perfusion resulting in more devitalization and in turn results in more devitalized tissues which are perfect pabulum for the bacterial proliferation. Thus, reverberating ischemia-infection downhill cycle sets in the diabetic foot. Unless timely debridement and mechanical control of infection is achieved, this cycle ultimately is going to result in the amputation. Therefore, the first step in the DF-CLTI is control of invasive infection and then early revascularization. There are several studies to this date reports that limb salvage rate is around 60% following the revascularization.[20]

There exists a morbid connexion between the group of patients whose DF-CLTI is unsalvageable and undergo amputation are also prone for preterminal coronary events with high mortality as shown by the EURODIALE study.[1.2.21] Therefore, the logical conclusion is saving the foot or residuum of foot indirectly saves the lives of these patients. “Saving limb and foot is therefore saving a life.” One can also reasonably come in to this conclusion after analyzing the sequel of major limb amputation. For example, a below knee amputation increases the walking metabolic equivalents by 110% which imposes severe demand[43] on the myocardium which is already receiving limited perfusion from the coronary atherosclerosis this may easily precipitate the preterminal coronary event. Thus, the timely revascularization and microvascular reconstruction, which rapidly replenishes the healing potential at recipient site, goes a long way in saving the limb and in turn saving the life.[44],[45],[46]

Balakrishnan et al.[2] in their study established that the microvascular reconstruction using the hip or above hip level perforasomal flaps in the revascularized diabetic foot, that brought tissues free from the microangiopathy resulting in the early and stable reconstructions. Perforasomes-oriented reconstruction in DF-CLTI – “perforasomes replacement for perforasomes” embarking on the super microsurgical approach in salvaging the DFCLTI foot was popularized by Hyun Suk Suh et al.[46] Well-vascularized perforator flap-based reconstruction and anastomosing it to the pulsatile perforator is a step forward in the perforasomes-oriented reconstruction of DF-CLTI [Figure 2]. With no steal phenomenon, the supermicrovascular surgery can be performed with perforator flaps with any collateral vessels or the branches of augmented source vessel that has the flow velocity of 30–40 cm/s [Figure 2]. Replenishing the perfusion and wound healing potential by early intervention distal bypass facilitates the perforator-based local flap reconstruction in the ischemic diabetic foot [Figure 3].
Figure 2: (a) A case of DCLTI with medial and lateral calcaneal perforasomes involved (b). Targeted pathway for the revascularization of the above perforasomes (c). 6 weeks post revascularization status. (d) Perforasome-directed revascularization using the anterolateral thigh perforator flap (e). One-year postoperative result

Click here to view
Figure 3: (a). Patient with severe rest pain and heel ulcer. (b) Catheter angiogram reveals the PO GLASS category in the inframalleolar vessels with involvement of medial calcaneal artery perforasome alone. (c). Popliteal to distal posterior tibial bypass (d) Late picture of salvage reconstruction using the local rotation flap

Click here to view

  Conclusions Top

Evidence-based IPDDR when performed timely leads to the salvage of all the potentially ischemic tissues in the DF-CLTI. Establishment of straight line flow to the involved perforasome with periwound blush as an end point of successful revascularization should facilitate the timely performed perforasomes-based reconstruction culminating in the shoeable and stable diabetic foot or foot residuum.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Balakrishnan TM, Ilayakumar P. Microvascular reconstruction in the revascularised diabetic foot: A perforasome approach. Clin Res Foot Ankle 2016;4:206.  Back to cited text no. 1
Balakrishnan TM, Paramasivam I, Thirunavukarasu K, Janardhanan J, Narayanan S. Limb salvage using microvascular reconstructions for secondary regional vascular insufficiency in the neuro ischemic diabetic foot; Is it making impact? Indian J Vasc Endovasc Surg 2019;6:65-73.  Back to cited text no. 2
  [Full text]  
Suh HS, Oh TS, Hong JP. Innovations in diabetic foot reconstruction using super microsurgery. Diabetes Metab Res Rev 2016;32;275-80.  Back to cited text no. 3
Wraight PR, Lawrence SM, Campbell DA, Colman PG. Creation of a multidisciplinary, evidence based, clinical guideline for the assessment, investigation and management of acute diabetes related foot complications. Diabet Med 2005;22:127-36.  Back to cited text no. 4
Manchot C. The Cutaneous Arteries of the Human Body. New York: Springer-Verlag; 1983.  Back to cited text no. 5
Salmon M. Arteries of the Skin. London: Churchill Livingstone; 1988.  Back to cited text no. 6
Cormack GC, Lamberty BG. Fasciocutaneous vessels. Their distribution on the trunk and limbs, and their clinical application in tissue transfer. Anat Clin 1984;6:121-31.  Back to cited text no. 7
Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: Experimental study and clinical applications. Br J Plast Surg 1987;40:113-41.  Back to cited text no. 8
Taylor GI, Caddy CM, Watterson PA, Crock JG. The venous territories (venosomes) of the human body: Experimental study and clinical implications. Plast Reconstr Surg 1990;86:185-213.  Back to cited text no. 9
Morris SF, Taylor GI. Predicting the survival of experimental skin flaps with a knowledge of the vascular architecture. Plast Reconstr Surg 1993;92:1352-61.  Back to cited text no. 10
Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42:645-8.  Back to cited text no. 11
Koshima I, Moriguchi T, Fukuda H, Yoshikawa Y, Soeda S. Free, thinned, paraumbilical perforator-based flaps. J Reconstr Microsurg 1991;7:313-6.  Back to cited text no. 12
Koshima I, Soeda S. Free posterior tibial perforator-based flaps. Ann Plast Surg 1991;26:284-8.  Back to cited text no. 13
Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678-83.  Back to cited text no. 14
Koshima I, Moriguchi T, Etoh H, Tsuda K, Tanaka H. The radial artery perforator-based adipofascial flap for dorsal hand coverage. Ann Plast Surg 1995;35:474-9.  Back to cited text no. 15
Koshima I, Urushibara K, Inagawa K, Hamasaki T, Moriguchi T. Free medial plantar perforator flaps for the resurfacing of finger and foot defects. Plast Reconstr Surg 2001;107:1753-8.  Back to cited text no. 16
Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Urushibara K, Inagawa K, et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg 2004;113:233-40.  Back to cited text no. 17
Koshima I, Narushima M, Mihara M, Iida T, Gonda K, Uchida G, Nakagawa M. New thoracodorsal artery perforator (TAPcp) flap with capillary perforators for reconstruction of upper limb. J Plast Reconstr Aesthet Surg 2010;63:140-5.  Back to cited text no. 18
Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124:1529-44.  Back to cited text no. 19
The Sage Group. Diabetic Foot Ulcers, Peripheral Arterial Disease and Critical Limb Ischemia. Available from: [Last accessed on 2018 Dec 17].  Back to cited text no. 20
Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, et al. Prediction of outcome in individuals with diabetic foot ulcers: Focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia 2008;51:747-55.  Back to cited text no. 21
Ryu HM, Kim JS, Ko YG, Hong MK, Jang Y, Choi DH. Comparison of clinical outcome of infrapopliteal angioplasty between Korean diabetic and non-diabetic patients with critical limb ischemia. Circ J 2012;76:335-41.  Back to cited text no. 22
Armstrong DG, Cohen K, Courric S, Bharara M, Marston W. Diabetic foot ulcers and vascular insufficiency: Our population has changed, but our methods have not. J Diabetes Sci Technol 2011;5:1591-5.  Back to cited text no. 23
Prompers L, Huijberts M, Apelqvist J, Jude E, Piaggesi A, Bakker K, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia 2007;50:18-25.  Back to cited text no. 24
Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care 1999;22:1029-35.  Back to cited text no. 25
Limperopoulou D, Bates M, Petrova NL, Me E. The epidemic of neuroischaemic foot. In: Diabetic Foot Study Group. Chalkidiki, Athens, Greece: Chalkidiki; 2005.  Back to cited text no. 26
Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003;361:1545-51.  Back to cited text no. 27
Akbari CM, LoGerfo FW. Microvascular changes in the diabetic foot. In: Veves A, Giurini J, LoGerfo FW, editors. The Diabetic Foot. Totowa: Humana; 2002.  Back to cited text no. 28
Li Y, Zhao L, Yu D, Ding G. The prevalence and risk factors of dyslipidemia in different diabetic progression stages among middle-aged and elderly populations in China. PLoS One 2018;13:e0205709.  Back to cited text no. 29
Pendsey SP. Understanding diabetic foot. Int J Diabetes Dev Ctries 2010;30:75-9.  Back to cited text no. 30
Liu C, Ponsero AJ, Armstrong DG, Lipsky BA, Hurwitz BL. The dynamic wound microbiome. BMC Med 2020;18:358.  Back to cited text no. 31
Aboyans V, Ricco JB, Bartelink ME, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur Heart J 2018;39:763-816.  Back to cited text no. 32
Utsunomiya M, Nakamura M, Nakanishi M, Takagi T, Hara H, Onishi K, et al. Impact of wound blush as an angiographic end point of endovascular therapy for patients with critical limb ischemia. J Vasc Surg 2012;55:113-21.  Back to cited text no. 33
Attinger CE, Evans KK, Bulan E, Blume P, Cooper P. Angiosomes of the foot and ankle and clinical implications for limb salvage: Reconstruction, incisions, and revascularization. Plast Reconstr Surg 2006;117:261S-293S.  Back to cited text no. 34
Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998;21:855-9.  Back to cited text no. 35
Margolis D, Malay DS, Hoffstad OJ, Leonard CE, MaCurdy T, Lopez de Nava K, et al. Prevalence of Diabetes, Diabetic Foot Ulcer, and Lower Extremity Amputation among Medicare Beneficiaries, 2006 to 2008. Rockville: Quality AfHRa; 2011.  Back to cited text no. 36
Neville RF, Attinger CE, Bulan EJ, Ducic I, Thomassen M, Sidawy AN. Revascularization of a specific angiosome for limb salvage: Does the target artery matter? Ann Vasc Surg 2009;23:367-73.  Back to cited text no. 37
Clemens MW, Attinger CE. Angiosomes and wound care in the diabetic foot. Foot Ankle Clin 2010;15:439-64.  Back to cited text no. 38
Clemens MW, Attinger CE. Functional reconstruction of the diabetic foot. Semin Plast Surg 2010;24:43-56.  Back to cited text no. 39
Effendi M, Ha AY, Felder JM 3rd. Foot salvage with selective arterialization of pedal venosomes. Plast Reconstr Surg Glob Open 2020;8:e2612.  Back to cited text no. 40
Gandini R, Merolla S, Scaggiante J, Meloni M, Giurato L, Uccioli L, et al. Endovascular distal plantar vein arterialization in dialysis patients with no-option critical limb ischemia and posterior tibial artery occlusion: A technique for limb salvage in a challenging patient subset. J Endovasc Ther 2018;25:127-32.  Back to cited text no. 41
Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019;69:3S-125.e40.  Back to cited text no. 42
Jetté M, Sidney K, Blümchen G. Metabolic equivalents (METS) in exercise testing, exercise prescription and evaluation of functional capacity. Clin Cardiol 1990;13:555-65.  Back to cited text no. 43
Mills JL, Conte MS, Armstrong DG, Pomposelli F, Schanzer A, et al. The society for vascular surgery lower extremity threatened limb classification system: Risk stratification based on Wound, Ischemia and foot Infection (WIfI). J Vasc Surg 2014;59:220-34.  Back to cited text no. 44
Hinchliffe RJ, Andros G, Apelqvist J, Bakker K, Friederichs S, Lammer J, et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev 2012;28 Suppl 1:179-217.  Back to cited text no. 45
Suh HS, Oh TS, Lee HS, Lee SH, Cho YP, Park JR, et al. A new approach for reconstruction of diabetic foot wounds using the angiosome and supermicrosurgery concept. Plast Reconstr Surg 2016;138:702e-9.  Back to cited text no. 46


  [Figure 1], [Figure 2], [Figure 3]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
   Changing Pattern...
   DF-CLTI: A Conun...
   Why Perforasome ...
   Article Figures

 Article Access Statistics
    PDF Downloaded89    
    Comments [Add]    

Recommend this journal