Upload
ellie-bedell
View
213
Download
0
Tags:
Embed Size (px)
Citation preview
Y A L E S C H O O L O F M E D I C I N E
Author : John K. Forrest, M.DUpdated : June 2009
Endovascular Treatment of Critical Limb Ischemia
Krishnan Ramaraj, MD
Section of CardioVASCULAR Medicine
Y A L E S C H O O L O F M E D I C I N E
Author : John K. Forrest, M.DUpdated : June 2009
Southern Regional AHEC adheres to ACCME Essential Areas and Policies regarding industry support of continuing medical education. All those in a position to control content have disclosed and there are no unresolved conflicts prior to this program.
The following presenters and panelists (and their family members) have no relevant financial disclosures to make:
Krishnan Ramaraj, MD
(910) 615-4000| 1638 Owen Drive | Fayetteville, NC 28304
There will not be discussion of any off-label, experimental, or investigational use of drugs or devices in this presentation
This program is not being supported by any commercial funding.
Y A L E S C H O O L O F M E D I C I N E
- ~314,000 cases annually in the United
States
- 5-year mortality estimated at >50%
- 2.7 billion dollars spent in-hospital on
CLI in 2007
- Endovascular-first and bypass-first
strategies appear to provide equivalent
long-term limb salvage rates
Scope of CLI
Moridzadeh R, et al. Subsequent open surgical revascularization following an initial endovascular approach for critical limb ischemia. Presented at: Annual Meeting of Eastern Vascular Society; September 12-15, 2012; Pittsburgh, PA
Y A L E S C H O O L O F M E D I C I N E
- ~30% of Medicare patients undergo
primary amputation as the only therapy
provided- 60% of amputations occur without any revascularization
attempt
- 46-73% of amputations occur without a diagnostic
angiogram
- Estimated 2010 Medicare cost of major
amputation exceeds $10 billion US
dollars
Scope of CLI
Yost ML. The economic cost of dysvascular amputation. Atlanta (GA): The Sage Group; 2013. In press.
Baser O, et al. Prevalence, incidence, and outcomes of critical limb ischemia in the US Medicare population. Vasc Dis Mgmt. 2013:10; E26-36.
Y A L E S C H O O L O F M E D I C I N E
63 yr-old female
Insulin-Dependent DiabetesHypertensionHeavy Smoker
COPDPrior Transmetatarsal amputation on the R
Case Presentation
Y A L E S C H O O L O F M E D I C I N E
Early September 2012Non-healing ulcer at tip of L great toe
Late September 2012L great toe osteomyelitis
Partial L hallux amputationRunoff without inflow disease and only the
peroneal in-line to foot Peroneal angioplasty performed
Case Presentation
Y A L E S C H O O L O F M E D I C I N E
Jan 2013 Admitted with fever and non-healing
amputation site
Regadenoson stress with moderate anterior ischemia and TID, anterior hypo
in stress images, preserved LVEF
Case Presentation
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
63 year-old diabetic smoker with COPD and prior transmetatarsal amputation on
the R
Non-healing L partial hallux amputation site, despite recent peroneal angioplasty
High-risk stress test with 3-vessel CAD, including mid-LAD CTO
NOW WHAT??!!
Case Presentation
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Above kneePopliteal
Below knee
Anterior TibialTibio-Peroneal Trunk
PeronealPosterior Tibial
Y A L E S C H O O L O F M E D I C I N E
- When revascularization is not attempted in diabetics with CLI, major amputation occurs >50% at 5-year follow-up
- With DIRECT revascularization, major amputation is reduced to ~15% at 5-year follow-up
Angiosome Concept
Faglia E, et al. Long-term prognosis of diabetic patients with critical limb ischemia: a population-basedcohort study. Diabetes Care. 2009;32:822-827.
Y A L E S C H O O L O F M E D I C I N E
1MEDIAL CALCANEAL
2MEDIAL PLANTAR
3LATERAL PLANTAR
5LATERAL CALCANEAL
4DORSALIS PEDIS
PosteriorTibial
Peroneal
Anterior Tibial
Y A L E S C H O O L O F M E D I C I N E
2.
3.
1.
4.
5. MEDIAL CALCANEAL
MEDIAL PLANTAR
LATERAL PLANTAR
DORSALIS PEDIS
LATERAL CALCANEAL
PTa.
ATa.
Peroneal
PTa.
PTa.
Y A L E S C H O O L O F M E D I C I N E
Posterior Tibial Angiosome
Medial Calcaneal (Artery) Angiosome
Medial Plantar (Artery) Angiosome
Lateral Plantar (Artery) Angiosome
Y A L E S C H O O L O F M E D I C I N E
Revascularization of a Specific Angiosome for Limb Salvage: Does the Target Artery Matter?
Neville RF, Attinger CE, Bulan EJ, Thomassen M, Sidawy ANAnnals of Vascular Surgery
Volume 23, Issue 3, May–June 2009, 367–373
- Investigated whether bypass to artery directly feeding the ischemic angiosome had an impact on wound healing and limb salvage- Retrospective review of all wounds (n=52) requiring tibial bypass over 2 year period- Patients divided based on pre-op angiograms:
- DIRECT REVASCULARIZATION BYPASS TO THE ARTERY DIRECTLY FEEDING ISCHEMIC ANGIOSOME (n=27)- INDIRECT REVASCULARIZATION BYPASS UNRELATED TO ISCHEMIC ANGIOSOME (n=25)
- Endpoints: complete healing, amputation, death unrelated to the wound, and time to healing for healed wounds
Y A L E S C H O O L O F M E D I C I N E
Revascularization of a Specific Angiosome for Limb Salvage: Does the Target Artery Matter?
Neville RF, Attinger CE, Bulan EJ, Thomassen M, Sidawy ANAnnals of Vascular Surgery
Volume 23, Issue 3, May–June 2009, 367–373
19% mortality rate during follow-up
65% SVG35% PTFE
1 bypass failed periop
Y A L E S C H O O L O F M E D I C I N E
Revascularization of a Specific Angiosome for Limb Salvage: Does the Target Artery Matter?
Neville RF, Attinger CE, Bulan EJ, Thomassen M, Sidawy ANAnnals of Vascular Surgery
Volume 23, Issue 3, May–June 2009, 367–373
Statistically significant difference in complete healing rate with p = 0.03
(Fisher's exact test).
9% amputation rate in Direct Revasc
38% amputation rate in Indirect Revasc
Y A L E S C H O O L O F M E D I C I N E
Durability of the Tibial Artery Bypass in Diabetic Patients
Shah DM, Chang BB, Fitgerald KM, Kaufman JL, Leather RPAmerican Journal of Sugery
Volume 156, Issue 2, August 1988, 133-135
- Single-center, large, prospective comparison of patency for femoral-to-tibial SVG bypass in diabetics (n=387) and non-diabetics (n=294)
- 681 bypasses over 7-yr period, all performed for limb salvage
- More patients in diabetic arm had gangrene or frank tissue loss
- Cumulative patency rates followed to 5 yrs
Y A L E S C H O O L O F M E D I C I N E
Durability of the Tibial Artery Bypass in Diabetic Patients
Shah DM, Chang BB, Fitgerald KM, Kaufman JL, Leather RPAmerican Journal of Sugery
Volume 156, Issue 2, August 1988, 133-135
- 30% 5-yr mortality for diabetics- 4% operative mortality across both arms
Y A L E S C H O O L O F M E D I C I N E
Popliteal-to-Distal Bypass for Limb Salvage
Grego F, Antonello M, Stramana R, Deriu GP, Lepidi SAnnals of Vascular Surgery
Volume 18, Issue 3, May 2004, 321-328
Life-table analysis of primary and secondary patency (A)
and limb salvage and survival rates (B) at 5 years.
Limb Salvage
Survival
Secondary Patency
Primary Patency
Y A L E S C H O O L O F M E D I C I N E
Popliteal-to-Distal Bypass for Limb Salvage
Grego F, Antonello M, Stramana R, Deriu GP, Lepidi SAnnals of Vascular Surgery
Volume 18, Issue 3, May 2004, 321-328
Life-table analysis of primary patency rates of SVG and PTFE bypass.
Saphenus Vein
PolyTetraFluoroEthylene
Y A L E S C H O O L O F M E D I C I N E
The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index
in vascular surgery patientsBertges DJ, Goodney PP, Likolsky DS, Cronenewett JL
Journal of Vascular SurgeryVolume 52, Issue 3, September 2010, 674-683
Y A L E S C H O O L O F M E D I C I N E
The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index
in vascular surgery patientsBertges DJ, Goodney PP, Likolsky DS, Cronenewett JL
Journal of Vascular SurgeryVolume 52, Issue 3, September 2010, 674-683
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
1MEDIAL CALCANEAL
2MEDIAL PLANTAR
3LATERAL PLANTAR
5LATERAL CALCANEAL
4DORSALIS PEDIS
PosteriorTibial
Peroneal
Anterior Tibial
Y A L E S C H O O L O F M E D I C I N E
2.
3.
1.
4.
5. MEDIAL CALCANEAL
MEDIAL PLANTAR
LATERAL PLANTAR
DORSALIS PEDIS
LATERAL CALCANEAL
PTa.
ATa.
Peroneal
PTa.
PTa.
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Y A L E S C H O O L O F M E D I C I N E
Patients with CLI requiring BTK revascularization have high degree of cardiac
morbidity and mortality at baseline.
Lower extremity bypass surgery caries high-degree of perioperative morbidity and
mortality for patients with coexistent CAD
Angiosome principle must be employed to maximize wound-healing.
Summary
Y A L E S C H O O L O F M E D I C I N E
Percutaneous endovascular therapies for CLI are emerging.
Investigation into long-term patency and adequacy of wound-healing after
percutaneous revascularization is needed.
Summary
Y A L E S C H O O L O F M E D I C I N E
Thank You.
Case Presentation