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Prof. Dr. med. Nicolas Diehm, MBA Interventional Angiology
Kantonsspital Aarau, Switzerland
The Swiss Experience with ambulatory treatment of
claudicants and CLI patients
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Financial Disclosures
Consultancy / royalties / speaker honoraria: Medtronic, Biotronik, genae, Medicut
Research grants:
Swiss Heart Foundation, Biotronik, Kantonsspital Aarau Research Fund, Gotthard Schettler Foundation, Medtronic
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Practical Considerations Inpatient versus outpatient angioplasty
• Patient factors: clinical presentation, fitness, comorbidities, patient logistics.
• Technical details of revascularization.
• Access closure.
• Reimbursement.
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Patient factors • Clinical presentation (claudication versus CLI). • Patient fitness / comorbidities (renal
insufficiency, need for hydration, etc.). • Patient logistics (dependency status). • Primary care physician.
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Preprocedural planning • Clinical / hemodynamic workup.
• Duplex sonography: Length and severity of obstruction, imaging of arterial access.
• Advanced imaging (CTA, MRA) rarely required.
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Technical Details Type of catheter treatment required (angioplasty / stenting, atherectomy, multilevel treatment, lysis).
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Clinical Case I Outpatient Management of Claudication
• 70-year old claudicant, CVFR: cigarette smoking, arterial HT • Nitinol stenting infrarenal aortic stenosis, 10F, Angio-seal 8F.
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Clinical Case II Outpatient Management of CLI
• 69-year old CLI patient, chronic ulceration right big toe, CVRF: cigarette smoking, DM type II, arterial hypertension, hyperlipidemia, chronic renal insufficiency, ventricular fibrillation with embolic damages to both feet and subsequent calf amputation left side.
• Prior PTA of anterior tibial artery 10 months ago
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Immediate Angiographic Result
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Reimbursement Inpatient
Technically complex endovascular procedures in claudicants (re-entry systems, multiple stents, atherectomy) may not be covered in inpatients.
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Access closure StarClose versus manual compression
• Randomized multicenter study to compare StarClose versus manual compression
• 596 patients • StarClose non-inferior to manual compression • StarClose significantly reduced time to hemostasis, ambulation,
and dischargeability when compared with compression.
Hermiller et al. Catheterization and Cardiovascular Interventions 68:677–683 (2006)
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• Outpatient treatment of patients treated for both claudication and critical limb ischemia is feasible.
• Clinical and procedural factors determine eligibility for outpatient treatment.
• Reimbursement may impact decision for outpatient treatment.
Conclusions
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Prof. Dr. med. Nicolas Diehm, MBA Interventional Angiology
Kantonsspital Aarau, Switzerland
The Swiss Experience with ambulatory treatment of
claudicants and CLI patients