evolution of limb salvage technics & where they are going: from amputation to bypass to endovasc...

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