cardio assiut 2010 final_ by dr moustafa elshal _ medics index member

8/9/2019 Cardio ASSIUT 2010 Final_ by Dr Moustafa Elshal _ Medics Index Member

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Surgical treatment for diabetic foot

revascularization

Surgical treatment for diabetic foot

revascularization

Dr. Moustafa Abd Elhamid ElshalSpecialist of Vascular Surgery ,Endovascular Intervention

Surgeries and Diabetic Foot managementNational Institute Of Diabetes and Endocrinology (NIDE)

Cairo - Egypt

Tele : 0113437474 - 0106011656

2010

Dr. Moustafa Abd Elhamid ElshalSpecialist of Vascular Surgery ,Endovascular Intervention

Surgeries and Diabetic Foot managementNational Institute Of Diabetes and Endocrinology (NIDE)

Cairo - Egypt

Tele : 0113437474 - 0106011656

2010
http://www.medicsindex.com/


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Epidemiological DataEpidemiological DataEpidemiological DataEpidemiological Data

Prevalence 7% to 15% in themiddle aged and theelderly(Cuschieri 2002)

20% in over 75(Hiatt 1995)

Coronary artery diseasecoexist in 68% & Strokecoexist in 42% (Ness &Aronow 1999)

Classified along with other

cardiovascular diseases it isthe commonest cause ofmortality in UK. (Males300/100,000/yr, andFemales 190/100,000/yr)

Prevalence 7% to 15% in themiddle aged and theelderly(Cuschieri 2002)

20% in over 75(Hiatt 1995)

Coronary artery diseasecoexist in 68% & Strokecoexist in 42% (Ness &Aronow 1999)

Classified along with other

cardiovascular diseases it isthe commonest cause ofmortality in UK. (Males300/100,000/yr, andFemales 190/100,000/yr)

Amputation rate within oneyear of diagnosis is 10-40%(Dormandy 1999)

Mortality after amputation:

1 year = 20%5 years = 40% - 70%

10 years = 80% - 95%

Second most common cause ofdisability in the UK (WHO)

Prevalent in deprived areas

Amputation rate within oneyear of diagnosis is 10-40%(Dormandy 1999)

Mortality after amputation:

1 year = 20%5 years = 40% - 70%

10 years = 80% - 95%

Second most common cause of

disability in the UK (WHO)

Prevalent in deprived areas


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NEUROPATHYNEUROPATHYNEUROPATHYNEUROPATHY

Thickening of nutrient vessels of nerves leading to N. ischemiaThickening of nutrient vessels of nerves leading to N. ischemia

Increased activity of sorbitol pathway , demyelination and impairedIncreased activity of sorbitol pathway , demyelination and impaired

velocity of peripheral n decreasing its conductionvelocity of peripheral n decreasing its conduction

Autonomic system affection leads to shutting of the arterio-venousAutonomic system affection leads to shutting of the arterio-venous

communications and decreased tissue perfusion even if normal Bl.communications and decreased tissue perfusion even if normal Bl.

SupplySupply

Diminished nocioceptive reflex leading to diminished response toDiminished nocioceptive reflex leading to diminished response to

inflammationinflammation

Motor neuropathy decreases the N. stimulation of the intrinsic musclesMotor neuropathy decreases the N. stimulation of the intrinsic muscles

of the foot leading to its atrophy.of the foot leading to its atrophy.

Waisting of these muscles fails to maintain joint stability (charcot Joint)Waisting of these muscles fails to maintain joint stability (charcot Joint)

Foot deformity creates abnormal pressure areas and ulcersFoot deformity creates abnormal pressure areas and ulcers

Peripheral sensory neuropathy produces abolition of pain reflex leadingPeripheral sensory neuropathy produces abolition of pain reflex leadingto more ulcers, and ligament stretching and foot deformityto more ulcers, and ligament stretching and foot deformity

Thickening of nutrient vessels of nerves leading to N. ischemiaThickening of nutrient vessels of nerves leading to N. ischemia

Increased activity of sorbitol pathway , demyelination and impairedIncreased activity of sorbitol pathway , demyelination and impaired

velocity of peripheral n decreasing its conductionvelocity of peripheral n decreasing its conduction

Autonomic system affection leads to shutting of the arterio-venousAutonomic system affection leads to shutting of the arterio-venous

communications and decreased tissue perfusion even if normal Bl.communications and decreased tissue perfusion even if normal Bl.

SupplySupply

Diminished nocioceptive reflex leading to diminished response toDiminished nocioceptive reflex leading to diminished response to

inflammationinflammation

Motor neuropathy decreases the N. stimulation of the intrinsic musclesMotor neuropathy decreases the N. stimulation of the intrinsic muscles

of the foot leading to its atrophy.of the foot leading to its atrophy.

Waisting of these muscles fails to maintain joint stability (charcot Joint)Waisting of these muscles fails to maintain joint stability (charcot Joint)

Foot deformity creates abnormal pressure areas and ulcersFoot deformity creates abnormal pressure areas and ulcers

Peripheral sensory neuropathy produces abolition of pain reflex leadingPeripheral sensory neuropathy produces abolition of pain reflex leading

to more ulcers, and ligament stretching and foot deformityto more ulcers, and ligament stretching and foot deformity


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InfectionInfectionInfectionInfection

Risk of infection is higher with hyperglycemia due toRisk of infection is higher with hyperglycemia due to

suppression of the immunity systemsuppression of the immunity system

Diabetic albuminuria decreases tissue nutritionDiabetic albuminuria decreases tissue nutrition

Infection increases metabolism and oxygen consumptionInfection increases metabolism and oxygen consumption

Osteomyelitis due to penetrating infected ulcerOsteomyelitis due to penetrating infected ulcer

Risk of infection is higher with hyperglycemia due toRisk of infection is higher with hyperglycemia due to

suppression of the immunity systemsuppression of the immunity system

Diabetic albuminuria decreases tissue nutritionDiabetic albuminuria decreases tissue nutrition

Infection increases metabolism and oxygen consumptionInfection increases metabolism and oxygen consumption

Osteomyelitis due to penetrating infected ulcerOsteomyelitis due to penetrating infected ulcer

IschemiaIschemiaIschemiaIschemia Inadequate circulation increase tissueInadequate circulation increase tissue

necrosis and exacerbate infectionnecrosis and exacerbate infection

Macro vascularMacro vascular MicrovascularMicrovascular

Inadequate circulation increase tissueInadequate circulation increase tissue

necrosis and exacerbate infectionnecrosis and exacerbate infection

Macro vascularMacro vascular MicrovascularMicrovascular


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Risk FactorsRisk Factors

Non-modifiable:1. Age (mid & older)

2. Male gender(upto age 65)

3. Family history of

hyperlipidaemia(1:500)

4. Race (e.g,African-AmericansOR=2.3) Criqui

2005.

Non-modifiable:1. Age (mid & older)

2. Male gender(upto age 65)

3. Family history of

hyperlipidaemia(1:500)

4. Race (e.g,African-AmericansOR=2.3) Criqui

2005.

Modifiable:1. High blood pressure

2. Diabetes

3. Smoking (Buergersdisease)

4. Hyperlipidaemia

5. Obesity

6. Excessive alcohol

7. Sedentary life8. Stress & depression

9. Trauma

Modifiable:

1. High blood pressure

2. Diabetes

3. Smoking (Buergersdisease)

4. Hyperlipidaemia

5. Obesity

6. Excessive alcohol

7. Sedentary life8. Stress & depression

9. Trauma


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Intermittent ClaudicationIntermittent ClaudicationIntermittent ClaudicationIntermittent Claudication

Pain in the legs onwalking a certaindistance.

Associatedcardiovascular

morbidity

Disability (socialconsequences)

Dependence on

medicines. May require surgery

15% requireamputation within 1year (Martson 2006)

Pain in the legs onwalking a certaindistance.

Associatedcardiovascular

morbidity Disability (social

consequences)

Dependence on

medicines. May require surgery

15% requireamputation within 1year (Martson 2006)


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Critical IschaemiaCritical IschaemiaCritical IschaemiaCritical Ischaemia

Rest pain (ABI


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UlcersUlcersUlcersUlcers

500,000 with recurrent legulcers in UK (10% arterial)

Disability

Sepsis

Frequent hospitalzation

Surgical procedures

Amputation

Death

500,000 with recurrent legulcers in UK (10% arterial)

Disability

Sepsis

Frequent hospitalzation

Surgical procedures

Amputation

Death


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GangreneGangreneGangreneGangrene

Amputation

High risk of mortality

due to associated CVD.

Mortality 20%(1 yr), 40-

70%(5yr), 80-95%(10yr).

Burden on resources

Amputation

High risk of mortality

due to associated CVD.

Mortality 20%(1 yr), 40-

70%(5yr), 80-95%(10yr).

Burden on resources
http://www.medicsindex.com/http://www.medicsindex.com/


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LUMBAR SYMPATHECTOMY

1912 Leriche - Jaboulay

only alternative to amputation

MECHANISM:

t Increase blood flow by abolishing basal and reflexarteriolar constriction

t Alteration of pain impulse transmission

Temporary but significant

LUMBAR SYMPATHECTOMY

1912 Leriche - Jaboulay

only alternative to amputation

MECHANISM:

t Increase blood flow by abolishing basal and reflexarteriolar constriction

t Alteration of pain impulse transmission

Temporary but significant


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1960s direct vascularisation took over

INSITU VEINOUS BYPASS BECAME A VULGAR STANDARDTECHNIQUE

Distal peroneal bypass become a routine technique and

bypass to pedal arteries became unexceptionnel

1960s direct vascularisation took over

INSITU VEINOUS BYPASS BECAME A VULGAR STANDARDTECHNIQUE

Distal peroneal bypass become a routine technique and

bypass to pedal arteries became unexceptionnel


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1st author Year Graft N CLI% Tibial bypass 1 yr% 3 yr% 5 yr%

J. Gonzales-FAJARDO1ry patency rateLimb salvage

1998 165 100% 100%7882

6472

5770

Panayiotopoulos1ry patency rate2ry patency rateLimb salvage rate

1997 109 100% 82% (55vein)---

274553

---

Luther1ry patency rate2ry patency rateLimb salvage rate

1997 187 100% 100%57-

81

47-

71

Sayers1ry patency rate2ry patency rateLimb salvage rate

1993 78 62% 77%3363-

296467

Bergamini1ry patency rate2ry patency rateLimb salvage rate

1991 361 93% 68%739094

668590

638186

Rutherford1ry patency rate2ry patency rate

1988 170 98% 100%85-

78-

--

Shah- Diabetic

1ry patency rate2ry patency rate - Non Diabetic

1ry patency rate2ry patency rate

1988387

294

8596

8799

7786

8194

7472

7670

Patency and limb salvage using venous graft in femoro-below knee bypass


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Inflow state

Distal runoff and patency of pedal vessels

Primary and secondary procedures

Site of distal anastomosis

Availability of venous material

Technical feasibility

Age and gender Diabetes

Renal failure

Inflow state

Distal runoff and patency of pedal vessels

Primary and secondary procedures

Site of distal anastomosis

Availability of venous material

Technical feasibility

Age and gender

Diabetes

Renal failure

Limitations of Surgical techniqueLimitations of Surgical technique


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Venous material is the corner stone of these surgeries.

Synthetic graft cannot perform as the vein at the level

of tibial arteries anastomosis

Venous material is the corner stone of these surgeries.

Synthetic graft cannot perform as the vein at the level

of tibial arteries anastomosis

Lack of venous materialLack of venous material


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Our team experience from 2000-2005

28 distal tibial bypass (ankle level)

- 0% perioperative mortality

- 6 late deaths (cardiac and renal)

-12 pts (minor amput. Infected toes)

Primary graft patency 89.2 %

- 3 intraop occlusion needing revision

Secondary patency 75 % (2 years)

- 7 occluded during follow up needing majoramputation in 6 AK and 1 BK amputation

Limb salvage rate 75 % at 2 years and 64% at the end of the

study (5 years)

Our team experience from 2000-2005

28 distal tibial bypass (ankle level)

- 0% perioperative mortality

- 6 late deaths (cardiac and renal)

-12 pts (minor amput. Infected toes)

Primary graft patency 89.2 %

- 3 intraop occlusion needing revision

Secondary patency 75 % (2 years)

- 7 occluded during follow up needing majoramputation in 6 AK and 1 BK amputation

Limb salvage rate 75 % at 2 years and 64% at the end of the

study (5 years)


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Delayed healing in 8 patient- 4 of these patients progressed favorably

- 2 presented tissue necrosis treated by our

plastic surgeon

( free radial graft from the right upper limb withsuccessful healing)

2 patients manifested bypass erosion and 2ry

hemorrhage which necessitated above knee

amputation at 2 and 5 months

Delayed healing in 8 patient- 4 of these patients progressed favorably

- 2 presented tissue necrosis treated by our

plastic surgeon

( free radial graft from the right upper limb withsuccessful healing)

2 patients manifested bypass erosion and 2ry

hemorrhage which necessitated above knee

amputation at 2 and 5 months

ComplicationsComplications


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Post opertaive infection

3 patients at 2, 3, and 6 months

2 patients treated medically with aggressive repeated daily

dressings

1 patient developed septicemia with failure to control the

infection and necessitated above knee amputation over a

patent bypass.

Post opertaive infection

3 patients at 2, 3, and 6 months

2 patients treated medically with aggressive repeated daily

dressings

1 patient developed septicemia with failure to control the

infection and necessitated above knee amputation over a

patent bypass.

ComplicationsComplications


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Right poplito posterior tibial venous bypassRight poplito posterior tibial venous bypass


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Perfect knowledge of all possible techniques

He must operate under supervision for at least 20

cases before operating them alone.

These techniques are time consuming and need apatient surgeon

Complete understanding of the importance to

accomplish this difficult task.

In a specialized center, two surgeons may

operate together reducing this operating time

Perfect knowledge of all possible techniques

He must operate under supervision for at least 20

cases before operating them alone.

These techniques are time consuming and need apatient surgeon

Complete understanding of the importance to

accomplish this difficult task.

In a specialized center, two surgeons may

operate together reducing this operating time

High training skillsHigh training skills


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Tibial endovascular techniqueTibial endovascular technique

Revascularization of multiple lesions at a timeRevascularization of multiple lesions at a time Shorter timeShorter time

No wounds in fragile patientsNo wounds in fragile patients

Less risk of infection in diabetic and Stage IV ptsLess risk of infection in diabetic and Stage IV pts

No risk for anesthesiaNo risk for anesthesia

No arterial clamping and shorter ischemia timeNo arterial clamping and shorter ischemia time

No external dissection traumaNo external dissection trauma

- SubintimalSubintimal- Balloon angioplastyBalloon angioplasty- StentingStenting- Balloon angioplasty andBalloon angioplasty and

rare stentingrare stenting


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CONCLUSIONCONCLUSIONCONCLUSIONCONCLUSION

Treatement of diabetic foot need multidisciplinary approach Prevention has better results than interventions

Angioplasty in patients with multi-segmental and longocclusions of the lower limb arteries is a feasible, safe, andeffective procedure more advantage than surgery

Open surgical procedures have been largely replaced in ourinstitute by angioplasty with a better outcome. They areactually reserved for lesions technically unsuitable forendovascular procedures

Treatement of diabetic foot need multidisciplinary approach Prevention has better results than interventions

Angioplasty in patients with multi-segmental and longocclusions of the lower limb arteries is a feasible, safe, andeffective procedure more advantage than surgery

Open surgical procedures have been largely replaced in ourinstitute by angioplasty with a better outcome. They areactually reserved for lesions technically unsuitable forendovascular procedures


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cardio assiut 2010 final_ by dr moustafa elshal _ medics index member

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