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.d updated : june 2009...

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

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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.

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- ~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

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- ~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.

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63 yr-old female

Insulin-Dependent DiabetesHypertensionHeavy Smoker

COPDPrior Transmetatarsal amputation on the R

Case Presentation

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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

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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

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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

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Above kneePopliteal

Below knee

Anterior TibialTibio-Peroneal Trunk

PeronealPosterior Tibial

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- 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.

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1MEDIAL CALCANEAL

2MEDIAL PLANTAR

3LATERAL PLANTAR

5LATERAL CALCANEAL

4DORSALIS PEDIS

PosteriorTibial

Peroneal

Anterior Tibial

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2.

3.

1.

4.

5. MEDIAL CALCANEAL

MEDIAL PLANTAR

LATERAL PLANTAR

DORSALIS PEDIS

LATERAL CALCANEAL

PTa.

ATa.

Peroneal

PTa.

PTa.

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Posterior Tibial Angiosome

Medial Calcaneal (Artery) Angiosome

Medial Plantar (Artery) Angiosome

Lateral Plantar (Artery) Angiosome

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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

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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

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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

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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

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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

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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

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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

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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

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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

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1MEDIAL CALCANEAL

2MEDIAL PLANTAR

3LATERAL PLANTAR

5LATERAL CALCANEAL

4DORSALIS PEDIS

PosteriorTibial

Peroneal

Anterior Tibial

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2.

3.

1.

4.

5. MEDIAL CALCANEAL

MEDIAL PLANTAR

LATERAL PLANTAR

DORSALIS PEDIS

LATERAL CALCANEAL

PTa.

ATa.

Peroneal

PTa.

PTa.

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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

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Percutaneous endovascular therapies for CLI are emerging.

Investigation into long-term patency and adequacy of wound-healing after

percutaneous revascularization is needed.

Summary

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Thank You.

Case Presentation