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Steven KumVascular Surgeon
Department of SurgeryChangi General Hospital
Leaving Nothing Behind but an Open Artery
-
Advanced Limb Salvage for Tibial Disease
in a South Asian Population
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• 900 bed Tertiary Hospital• 12.7 % of adults are
diabetic• On average of 1 CLI per
day mostly due to Diabetes
• Vascular Team handles Revascularization and Wound Care/Reconstruction
• Simultaneous Revascularization and Soft Tissue work performed in Hybrid OR
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Clear Infection(within 48 hrs)
Revascularization (within 48 hrs)
Clean Granulating Wound
Skin Coverage/Reconstruction
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SMOKERS DIABETICS
Above the knee
Below the knee
MIXED
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Wound spans multiple angiosomes
Late presentation with severe tissue loss
Small vessels and long CTOs
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Angiosome Concept is even more important…
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Wound healing before restenosis
Early return to meaningful walking
function with freedom fromre-ulceration
1°
2°
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Endovascular CLI Strategy
R4Rest pain
R5Minor loss
R6Major loss
Revasc ATK +/- BTK Revasc ATK + BTK
Open singleAppropriate Angiosome
Able to open
Boundary Angiosome
only
Early definitive foot surgery and skin closure before restenosis
Close follow-up KIV Bypass
Open multipletibials especially if
high risk
•Wound across 2 angiosomes•Renal failure•Incomplete plantar arch•Large wound burden eg TMA•Non ambulatory status•High surgical risk
Consider earlybypass if wound deteriorates or unable to open angiosome Adapted from
Peter Schneider
Revasc ATK + BTK
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Direct Angiosome
Boundary Angiosome
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Direct Angiosome
Direct Angiosome
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1. Techniques in crossing lesions
2. Endovascular Adjuncts
3. Aggressive Wound Care
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Retrograde DP Puncture under Fluoro
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Renal Failure
Occluded Fem-PT bypass
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101 Patients
12m Angio
PTA arm PTA arm
60 Patients
10m Angio
33 Patients
6m Angio
11 Patients
12m Angio
67 Patients
12m Angio
58 Patients
3m Angio
PTA arm
1. D.Scheinert, J Am Coll Cardiol 2012;60:2290–5)
2. H.K.Soder, J Vasc Interv Radiol 2000; 11:1021–1031
3. F. Baumann, J Vasc Interv Radiol 2011; 22:1665–1673
4. F.Fanelli, J Endovasc Ther. 2012;19:571–580
5. F.Liistro, TCT 2012 oral presentation
6. A.Schmidt, Catheter Cardiovasc Interv. 2010 Dec 1;76(7):1047-54
BTK Restenosis RatesBTK TLR Rates
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Only ½ of the patients have complete healing at 6 months after bypass or PTA/stent for Rutherford 5/6 lesions.
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Patency important for wound healing
• makes healing faster and healing rates
higher
• Protects foot against recurrent
ulcerations
Primary Patency better than Secondary Patency
• reduces TLR and adds QoL
T.Kudo et al. The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: A 10-year experience. J Vasc Surg 2005;41:423-35.)Conte M.S Suggested objective performance goals and clinical trial design for evaluating catheter-based treatment of critical limb ischemia. JVS 2009;50:1462-1473
O.Iida et al. angiographic restenosis and its clinical impact after infrapoplitealangioplasty. Europ J of Vasc and Endovasc Surgery 2012
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Lesion length = 12 cm Occlusions = 80%
Angio: 81% (DEB) / 89% (PTA) Duplex: 18% (DEB) / 11% (PTA)
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RESULTS –BTK TREATED
US PATENCY AT 6 MONTHS
28
30 legs available for analysis
<50% stenosis
(n = 3) 10.0%
No restenosis
(n = 20)66.7%
Occluded
(n =2) 6.6%
All were focal
>50% stenosis
(n = 5)16.7%
All were focal
Re-stenosis rate: 23.3%
Clinically driven TLR was 10 % at 6 months
No or low grade stenosis: 76.7%
•63.3% occlusions
•60% Restenosis or ISR
•Lesion length > 12 cm
•86.7% moderate or severe
calcification
•100% R5/R6 CLI
> 50% stenosis defined by PSV ratio> 2
Clinical Distal Pulse felt in 83.3 % of patients
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1.F.Fanelli et al. JEVT 2012;19:571–580 2.A.Cioppa – EuroPCR 2012 3.F.Liistro – TCT 2012 2011
4. K.Suzuki – LINC Asia Pacific 2012 5. A.Schmidt et al. J Am Coll Cardiol2011;58:1105–9
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Endovascular CLI Strategy
R4Rest pain
R5Minor loss
R6Major loss
Revasc ATK +/- BTKRevasc ATK + BTK
Open singleAppropriate Angiosome
Able to open Boundary
Angiosomeonly (plantar arch intact)
Open multipletibials especially if
high risk
Revasc ATK + BTK
•Renal failure•Incomplete plantar arch•Large wound burden •High surgical risk
DEBEarly definitive foot surgery before restenosis
Close follow-up KIV Bypass
Consider earlybypass if wound deteriorates or unable to open angiosome
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DEB to P3 DEB to Lateral Plantar Artery
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12 months of patency wound
healing in 8 months
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Feb 2011
No restenosis seen
2 1/2 years
DEB from P3 to SFA
Aug 2013
Prev Full Metal Jacket for CLI now rest pain
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DEB to distal anastamosis, Popliteal and
Peroneal
Peroneal Occlusion
Stenosis
No restenosis
2 years post DEBFemoral –AK Pop bypass
withAcute Limb Ischaemia - Post Thrombolysis
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2 and half years post DEB
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Retrograde Double balloon
Stump of
bypass
Occluded Pop-DP bypass
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Nov 2013Feb 2011
DEB ATA
and DP
33 months
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Hyallomatrix and SSG
Calcified lesion
1 year post ATA and DP DEB
DP Biphasic
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ATA no significant stenosis 2 years post DEB
Initial angioshowing long ATA
Occlusion
2 years
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DEB from
plantar arch to ATA
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DEB from
plantar arch to ATA
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Oct 2011 Jan 2012 Aug 2012 Nov 2012Oct 2011
Pre Interention
Post Interention
Wound Healed
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Dec 2012 Nov 2013
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Drug Impregnated Bioabsorbable Stents in Asian Poplutaion Extremity Arterial Revascularization – DISAPEAR BTK Study
MRA
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Team based approach
EndocrinologyDM Centre
OrthopaedicsFoot & Ankle
PodiatryAnaesthesiaWound Care Team
Vascular Interventionalist
and Surgeon Family Physicians
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Necrotising Fascitis
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Rutherford Status and extent of tissue loss determines which BTK vessels need to be treated
Utilization of Adjuncts seems to answer the challenges of restenosis, re-intervention for long lesions with large wounds in the ATK and BTK segments
Extravascular care is important to “close the loop” and ensures a good angiographic result translates to a good clinical result