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EVOLUTION OF LIMB SALVAGE TECHNICS & WHERE THEY ARE GOING : FROM AMPUTATION TO BYPASS TO ENDOVASC Rx
FRANK J. VEITH SITE - 2013
BARCELONA – MAY 9, 2013
THE PAST
OLD HISTORY
STANDARD Rx AMPUTATION
IN THE 1960s &1970s SURGEONS CARED FOR CLI DEFINED AS REST PAIN, GANGRENE, ULCERATION
MORE HISTORY
WE BEGAN TO CHALLENGE THAT STANDARD (AMPUTATION)
IN THE LATE 1960s
83 YO DIABETIC GANGRENOUS TOE BYPASS 10 YEARS OFLIMB SALVAGE
UNUSUALLY EXCELLENT ARTERIOGRAPHY
1971 POSTERIOR TIBIAL
FIRST TO PUSH LIMB SALVAGE SURGERY & VERY AGGRESSIVE APPROACH TO LS (WITH BYP & PTA)
MY BACKGROUND STANDARD VASC SURGEON & ENDOVASCULAR ADVOCATE
• 1978 – LIMB SALVAGE & ILIAC PTA • 1988 – TIBIAL PTA; LATER SIPTA • 1992 – 1ST US EVAR WITH PARODI MARIN, SCHONHOLZ
& FIRST TO PUSH REDO BYP OR PTA WHEN 1ST BYP OR PTA FAILED OR WAS FAILING - UNUSUAL APPROACHES TO HELP
MOST OF OUR PATIENTS WERE DIABETIC ( > 70%) HENCE RELEVANCE TO DIABETIC FOOT CARE – CURRENT FAD
ONE EXAMPLE
78 YO DIABETIC AMP RECOM AT 3 NYC HOSPITALS NO SAPHENOUS V
1978
ASV PT BYPASS
ANGIO AFTER 4 YRS LIMB SALVAGE 6 YRS
EXTENSIVE FOOT & HEEL GANGRENE
AFTER ANT TIB BYPASS & DEBRIDEMENT & EXCISION OF ACHILLES TENDON
WALKING 6 YEARS LATER
FIRST TO DO VEIN BYPASSES TO VERY DISTAL PEDAL ARTERY BRANCHES
ANGIO AFTER 4 YRS
BYPASS TO LAT TARSAL PATENT >12 YRS
MORE THAN 98% OF PTS WITH CLI HAVE PATTERN OF DISEASE SUITABLE FOR REVASCULARIZATION BY OPEN OR ENDO RxS - VEITH, ANN SURG 1991
IS ALL THIS WORTHWHILE ?
CONCLUSIONS REGARDING PATIENTS WITH LIMBS THREATENED BY
INFRAINGUINAL ARTERIOSCLEROSIS
AGGRESSIVE USE OF ALL THESE & OTHER LIMB SALVAGE TECHNIQUES INCLUDING REOPS AND RE-PTAs WERE WORTHWHILE WHEN EMPLOYED IN 3700 CONSECUTIVE PATIENTS
ANN SURG 1981, 1991
REPETETIVE BYP OR PTA ARE THEY WORTHWHILE ? YES (5-14 PROCED) LIPSITZ, VEITH VASCULAR - APRIL 2013
1 OUTSTANDING Pt – 17 Yrs • Surgery #1 2/13/92
– EIA to CFA goretex – Fem-pop reversed GSV
• Surgery #2 1/31/94 – LàR fem-fem goretex – Thrombectomy of fem-pop
• Surgery #3 12/28/94 – Redo fem-fem goretex – Thrombectomy of fem-pop
• Surgery #4 11/10/95 – L EIA to R AKPop goretex – AKPop to BKPop vein
• Surgery #5 11/15/95 – Redo vein AKPop to BKPop
• Surgery #6 5/8/96 – L EIA to R vein graft goretex – Extension to TPT with vein
• Surgery #7 5/9/96 – Thrombectomy of goretex
• Surgery #8 8/22/96 – R CIA to PFA goretex – PFA to AT goretex – Thrombolysis 1/97 – Thrombolysis 8/97
• Surgery #9 1/3/02 – Thrombectomy of CIA to PFA – AT to AT LSV – CIA graft to AT graft goretex
• Surgery #10 1/4/02 – Thrombectomy of CIAàPFAàATàAT
• Surgery #11 2/20/02 – Thrombectomy of CIAàPFAàATàAT – Extension to distal AT goretex
• Surgery #12 6/17/02 – Thrombectomy of CIAàATàAT – Patch angioplasty of distal anastomosis
- New CIA-to-Perineal PTFE
13 BYPASSES
# 13 2003
AT FIRST OTHERS INCL OTHER SURGEONS & VS DOUBTED US & THOUGHT OUR AGGRESSIVE LIMB SALV APPROACH CRAZY NOW ACCEPTED
THE PRESENT IS
A CHANGING WORLD
IN LAST 5-10 YEARS SEA CHANGE IN TREATMENT OF INFRANGUINAL ASO
UP TO 10 YRS AGO Rx INFRAINGUINAL ASO PRIMARILY OPEN SURG SUPPLEMENTED BY CB RxS NOW RxS PRIMARILY ENDOV I.E. ENDOV IS FIRST OPTION - PTA, STENTS, SGs, ETC
THE CHANGE
INDEED THERE ARE NOW SOME WHO SAY NO ROLE FOR OPEN BYPASS SURGERY - “IF CAN’T Rx ENDO Rx WITH AMPUTATION” IS THIS RIGHT ???
COULD NOT BE MORE WRONG STILL A SUBSTANTIAL NUMBER OF PTS WITH INFRAING ASO WHO NEED OPEN SURG (BYP/TX) AT SOME TIME IN THEIR DISEASE COURSE PROPORTION VARIES ? 20-40%?
THE FUTURE
• MORE THAN 85% OF PROCEDURES FOR CLI WILL BE CATHETER BASED • MANY PROCEDURES WILL BE VERY DISTAL AND DIFFICULT • REDO PROCEDURES OFTEN WILL BE REQUIRED (CB/OP)
AS TECHNOLOGY IMPROVES
EVOLVING ENDOVASC OPTIONS WILL INCLUDE NEW TECHNOLOGIES
- EFFICACY MUST BE PROVEN BY GOOD RCTs - COST IS AN ISSUE
• TO IMPROVE BALLOON PTA & STENTING AT ALL LEVELS • TO IMPROVE OTHER CB RxS (LASER, ATHERO, CRYO, ETC) • ??? CELL OR GENE THERAPY
MY CONCLUSIONS
• INTERVENTIONAL Rx OF LE ASO IS HOTTEST NEW AREA IN VASCULAR DIS Rx • STATIN Rx WON’T DO IT HERE • GREAT NEED IN THIS AREA • MANY ADVANCES WILL BE MADE OVER NEXT DECADE
THE POSITIVES
MY CONCLUSIONS
• MANY VARIABLES • HARD TO PROVE Rx VALUE • NEED FOR HI LEVEL EVIDENCE & ENDOV SKILLS • ALWAYS NEED FOR OPEN Rx • COST IS BIG ISSUE • MUST BE SURE IS NEED TO Rx
NEGATIVES OR DIFFICULT
FINAL CONCLUSION • WHEN A PATIENT IS FACING AN AMPUTATION • WHETHER YOU ARE AN INTERVENTIONALIST OR SURGEON • NEVER, NEVER GIVE UP! - UNLESS YOUR PROCEDURE WILL TAKE THE PT’S LIFE
THANK YOU