Induced Angiogenesis for Limb Ischemia

Between May 1990 and April 2000, 61 patients with severe occlusive arterial disease (44 with thromboangiitis obliterans, 13 with atherosclerosis, and four with diabetes mellitus), who had not responded to previous nonsurgical and surgical treatment and had chronic critical ischemia in the lower limbs, had corticotomy near major neurovascular bundles and periosteal elevation along the whole length of the bone. This corticotomy consisted of elevation of a longitudinal window in the lateral cortex of the tibia to induce formation of neovascularity. The neovascularity is a part of the inflammatory response to fracture and periosteal elevation. The longest followup was 10 years and the shortest was 6 months. In 50 of 61 patients there was complete relief from pain at rest and indefinite postponement of amputation. Digital subtraction angiography studies before and after surgery showed the presence of a new vascular collateral network across the affected arteries, a process that improved the circulatory status of the ischemic limbs. The induced neovascularity acted as endogenous biologic bypass conduits and seemed to provide relief for patients with small and diffuse artery disease, when vascular reconstruction otherwise was impossible.