Amputation vs Revascularization Satish Muluk MD

System Director of Vascular Surgery Allegheny Health Network

Definition of Critical Limb Ischemia

• Ischemic Rest Pain • Ulceration • Gangrene

Progression of PAD symptoms (Rutherford)

Class 0 • Asymptomatic

Class 1-3 • Claudication

Class 4 • Ischemic rest

pain

Class 5 • Ulcer

Class 6 • Advanced

ulcer, Gangrene

Critical Limb Ischemia Ankle Pressure <60

ABI <0.4 Toe pressure <40

TcPO2 <40

Signs of CLI Nonhealing wounds

Shiny skin

Loss of hair growth

Asymmetric coolness

Pale or cyanotic skin

Pallor on elevation / Rubor of dependency

Not all patients with wounds or pain have CLI

• Diabetic neuropathy • Venous stasis ulceration • Lesions caused by embolization • Vasculitis

Natural history of CLI

At 1 year

Resolution

Persistent symptoms

Major amputation

Death

40% mortality at 1 year

50% fail to ambulate

Early Diagnosis Imaging

Revascularize • Endo vs Open

Preserve limb Surveillance

Ideal Treatment of CLI

Early diagnosis and intervention is crucial

Time is Limb

Interplay of wound, ischemia, infection

Score 0 (None) 1 (Mild) 2 (Moderate) 3 (Severe)

Wound No ulcer. IRP only

Minimal tissue loss, no

gangrene

Ulcer to tendon, joint, bone; digital

gangrene

Extensive tissue loss. Gangrene

beyond digit

Ischemia ABI ≥ 0.8

toe>60 mm ABI 0.6–0.79

toe 40-59 mm ABI 0.4–0.59

toe 30-39 mm ABI ≤ 0.39;

toe <30 mm

Infection No infection Cellulitis <2 cm Cellulitis>2 cm;

Abscess; Joint/bone

Systemic sepsis

“SVS iPG” app

Benefit of revascularization

Benefit of revascularization

Case Example: endovascular therapy • 76 year-old male • Smoker • Long hx of claudication • New onset right foot rest pain • No tissue loss • Optimal medical therapy

• Aspirin • Statin • Anti-hypertensive medications

• ABI 0.35

Case example: Open bypass

• 78 year-old • Smoker • Recent onset pain and gangrene of left toes 1-2

• Developed 1 week after nail clipping • Optimal medical therapy

• ASA • Statin • Anti-hypertensive

Severe tibial disease

Medial plantar artery

Distal bypass

Successful bypass

Leg incisions for bypass

Downsides of Revascularization

Technical failure

• Inability to restore perfusion • Initial or delayed failure (delayed failure esp with Endo revasc)

Clinical failure

• Technical success but lesion persists – esp with Endo revasc

Morbidity

• Wound complications – Open surgery • Cardiopulmonary – Open surgery

Mortality • High risk patient group – Open surgery

Risk-Benefit Analysis (Endo vs Open vs Conservative)

Avoid revasc

Non-ambulatory

Non-salvageable leg

Poor anatomy

Favor revasc

Functional

High WIfI

Avoid open

Cardio-pulmonary morbidity

Obesity

Poor conduit

Avoid endo

Heavy calcification

Common femoral lesions

Choosing between endo and open is not always easy

Endo better

Open better

Gray zone of equipoise:

BEST-CLI Trial

Avoidance of revascularization does not always mean primary amputation

Summary

Recognize limb threat Rest pain, wounds Early vascular surgery consult

WIfI scoring (prognosis, need for

revasc)

Optimal medical Rx Local Wound care

Endo Open

Conservative Primary Amputation

Surveillance after revascularization