The angiosome is a 3D structure which is

perfused by a single perforating artery (arteriosome) and

drained by a perforating vein (venosome). The concept

of arteriosome is applied in plastic surgery and in the

revascularization of ischemic limbs. Each venosome is also

drained by longitudinal veins running in the subcutaneous

layer. Accordingly, the concept of venosome cannot be

applied in the field of the venous disorders of the limbs.

The concept of phlebosome consider both paths of venous

drainage

Caggiati, Alberto

English

The angiosome is a 3D structure which is
perfused by a single perforating artery (arteriosome) and
drained by a perforating vein (venosome). The concept
of arteriosome is applied in plastic surgery and in the
revascularization of ischemic limbs. Each venosome is also
drained by longitudinal veins running in the subcutaneous
layer. Accordingly, the concept of venosome cannot be
applied in the field of the venous disorders of the limbs.
The concept of phlebosome consider both paths of venous
drainage

CAGGIATI, Alberto

Archivio della ricerca- Università di Roma La Sapienza

A  Caggiati - The Vascular architecture. Phlebosomes do they exist ? Vasculab  Journal of Theoretical and Applied Vascular Research (page 41) - JTAVR 2016;1(1):41-43VASCULAR RESEARCH VASCULAR BRANCHINGThe Vascular architecture. Phlebosomes do they exist ?A  Caggiati**Department of Anatomy, Sapienza University of Rome, Italy.presented to: the Hemodyn2015, Nov 2015, Naples, Italysubmitted: May 18, 2016, accepted: Jul 11, 2016, EPub Ahead of Print: Nov 30, 2016, published: Dec 31, 2016Conflict of interest: NoneCorresponding author: Prof. Alberto Caggiati, alberto.caggiati@uniroma1.it© 2016 Fondazione Vasculab impresa sociale ONLUS. All rights reserved.Abstract The angiosome is a 3D structure which isperfused by a single perforating artery (arteriosome) anddrained by a perforating vein (venosome). The conceptof arteriosome is applied in plastic surgery and in therevascularization of ischemic limbs. Each venosome is alsodrained by longitudinal veins running in the subcutaneouslayer. Accordingly, the concept of venosome cannot beapplied in the field of the venous disorders of the limbs.The concept of phlebosome consider both paths of venousdrainage.Keywords angiosome, arteriosome, venosome,phlebosomeThe integuments are perfused by perforating arteriesrunning along muscular septa before piercing the muscularfascia. Each artery perfuses a limited area of skin surfacewith the underlying subcutaneous fat. This block is called"arteriosome". At the boundaries of each arteriosome arevessels connecting the peripheral arteries of neighboringblocks. The concept of arteriosome is applied in the dailypractice by plastic surgeons since the mid of '901 and morerecently in the revascularization of ischemic limbs2-4.A similar arrangement was described with respect ofthe drainage of the cutaneous and subcutaneous layers1. Aperforating vein drains the plexuses of small veins runningparallel to the skin surface into the dermis and into thesubcutaneous layer (Figure 1).These veins are valvulated and converge from alldirection to form the root of the perforating vein. Thisvascular structure is more commonly stellate or medusoidin shape, similarly to saphenous tributaries at the Sapheno-Femoral Junction. In other body areas, the collecting veinsare polarized in one direction, as typically in the lateral thigh(Figure 2).Figure 1 - bidirectional avalvulated veins in red.Differences in the arrangement and polarization ofcollecting veins are related to the location, structure,function, embryological growth and differentiation1.The valvulated perforator drains the same blockof cutaneous and subcutaneous tissues perfused by thecorresponding perforating artery. This territory was named"venosome"1. At the boundaries of each venosome,avalvulated veins connect the peripheral valvulated veinA  Caggiati - The Vascular architecture. Phlebosomes do they exist ? Vasculab  Journal of Theoretical and Applied Vascular Research (page 42) - JTAVR 2016;1(1):41-43of adjacent blocks. These veins, were defined "oscillatingveins" because "..they allow free flow between thevalvulated channels of adjacent venosomes, whose valvesare oriented in an opposite direction.."1.Figure 2 - The collecting vein polarizes blood flow towarddeeper veins.The subdivision of the integuments in venosomes isrelated to the arrangement of the venous system in theembryo: the limb bud is drained by perforating veins whichconfluence into the primordial cardinal veins. In the nextphase of embryo development, veins running along themajor axis of the limb develop in the subcutaneous layer:firstly the (medial and lateral) marginal veins, then the greatsaphenous veins with their parallel accessories.These subcutaneous longitudinal veins play apredominant role in the drainage of the limb bud untilthe development of the deep ones, and actively participateto the drainage of venosomes . At the end of the firsttrimester of intrauterine life the deep veins develop (firstlythe sciatic, than the femoral) and the hemodynamic role ofthe longitudinal subcutaneous veins progressively reduces.However in the adult a double systems of blooddrainage persists: a vertical system (saphenous accessories,saphenous veins, the lateral plexus) and a transverse system(perforators). (Figure 3) This is why, at least in the inferiorlimb, the vascular arrangement of venosomes does notmirror that of arteriosomes. Moreover, the hemodynamicchanges observed in pathological conditions (i.e., varicosedisease) are not ascribable to the simple architectureof venosomes. For this reason, the term "phlebosome"looks to better correspond to the venous architectureof the cutaneous and subcutaneous layers in the lowerlimbs. These structures are simultaneously drained by bothperforating and longitudinal subcutaneous veins systems.Figure 3 - A) the architecture of arteriosomes. Oscillatingvessels in blu B) the architecture of venosomes. Avalvulatedoscillating veins in red. C) the architecture of phlebosomes.The peripheral arcades converge toward therespective perforator which pierces the muscular fasciato reach a deep vein. In other cases, it pierces thesaphenous fascia to be drained by the saphenous veins.The peripheral arcades of each phlebosome are alsoconnected by avalvulated veins to the peripheral ones ofthe neighboring phlebosomes (Figure 4). These avalvulatedveins are responsible for equilibration of flow and pressurebetween neighboring phlebosomes.In greater part of the phlebosomes of the inferiorlimbs it looks that the draining role of the perforator isovershadowed by that of the subcutaneous longitudinalvessels. This especially along the medial face of the limband the posterior leg due to the presence of the saphenousveins. In greater part of varicose limbs, the venouschanges are related to pathologic changes of longitudinalsubcutaneous veins (Figure 5). Only in few cases, it ispossible to observe a topographic relationship of signsand symptoms to a single "phlebosome": 1) the coronaflebectatica, 2) the clusters of varicose veins originatingfrom an incompetent perforator (escape point) and finally,3) varicose vein of the lateral thigh drained by a lateralperforator.A  Caggiati - The Vascular architecture. Phlebosomes do they exist ? Vasculab  Journal of Theoretical and Applied Vascular Research (page 43) - JTAVR 2016;1(1):41-43Figure 4 - Avalvulated oscillating veins connect theperipheral veins of neighboring venosomes.Figure 5 - A) reflux from an incompetent perforator withvaricose veins limited to the related phlebosome. B) refluxfrom a longitudinal vein with varicose veins extended tosame phlebosomes and drained by re-entry perforators.References1) Taylor GI, Caddy CM, Watterson PA, Crock JG. The venousterritories (venosomes) of the human body: experimental study andclinical implications. Plast Reconstr Surg 1990 Aug;86(2):185-213.2) Zheng XT, Zeng RC, Huang JY, Pan LM, Su X, WuZH, Yu GF. The Use of the Angiosome Concept for TreatingInfrapopliteal Critical Limb Ischemia through Interventional Therapyand Determining the Clinical Significance of Collateral Vessels. AnnVasc Surg. 2016 Apr;32:41-9. doi: 10.1016/j.avsg.2015.09.021.3) Alexandrescu V. Angiosomes applications in criticallimb ischemia. Minerva Medica, Torino, 2012. ISBN-13978-88-7711-766-3.4) Venermo M. Angiosome concept in the treatmentof critical limb ischaemia. Vascular News, 21st June2016. Available at http://vascularnews.com/angiosome-concept-in-the-treatment-of-critical-limb-ischaemia/ at the date of May 18, 2016.

The vascular architecture. Phlebosomes do they exist?

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The vascular architecture. Phlebosomes do they exist?

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