Limb Salvage in Diabetic Ischemic Foot. Kritaya Kritayakirana, MD, FACS Assistant Professor Chulalongkorn University April 30, 2017
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1 Limb Salvage in Diabetic Ischemic Foot Kritaya Kritayakirana, MD, FACS Assistant Professor Chulalongkorn University April 30, 2017
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4 Case Male 67 years old Underlying DM, HTN, TVD Present with gangrene at right big toe Orthopedic went on amputation early December 2016
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8 Endocrinologist Vascular surgeon Nurse coordinator Orthopedist PM&R Infectious Foot ankle specialist Cardiologist
9 KCMH 2016 BKA 38 AKA 28
10 Diabetic foot Presentations Ulceration Ankle destruction Prevention
11 The treatment of diabetic foot ulcers begins with A comprehensive assessment of the ulcer Patient's overall medical condition. Underlying neuropathy Bony deformity Peripheral artery disease
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13 Risk factor management Smoking cessation BP control <140/90: if DM <130/80 ACE inhibitors & beta blockers Cholesterol control LDL<100, HDL >35, Diabetes Management Hb A1c < 6% Pharmacotherapy Vasodilator agents: beraprost Antiplatelets: aspirin, clopidogrel Hemorrheologic agents: cilostazol Graded Exercise Regimen 30 minutes at least every other day
14 PAD Complication incidence Duration of Diabetes Mellitus and Incidence of Peripheral Artery Disease (PAD) Complications The longer diabetes history extends, the likelihood of the incidence of developing a PAD complication increases. (%) 40 Presumed duration of diabetes mellitus (years) [Subjects] 705 diabetic patients (406 male and 299 female patients) [Methods] The diagnosis with PAD was made when either of the followings was met: (1) ABI 0.8 (2) ABI 0.8 with pulse difference between right/left and confirmed presence of intermittent claudication (3) Calcification in the lower extremity with right/left pulse difference (4) Calcification in the lower extremity with the presence of intermittent claudication Murase T. et al. Clinical Endoclinology, 41(2): , 1993
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23 Wagner wound classification Grade 0 No ulcer in a high risk foot Grade 1 Superficial ulcer involving the full skin thickness but not underlying tissues Grade 2 Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation Grade 3 Deep ulcer with cellulitis or abscess formation, often with osteomyelitis Grade 4 Localized gangrene Grade 5 Extensive gangrene involving the whole foot
24 Grade 1 Superficial ulcer involving the full skin thickness but not underlying tissues
25 Grade 2 Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation
26 Grade 3 Deep ulcer with cellulitis or abscess formation, often with osteomyelitis
27 Grade 4 Localized gangrene
28 Surgery Indication when fail medical and exercise treatment PTA is preferred when possible in patients who are 50 years of age or younger, because they have a higher risk of graft failure after surgical therapy than do older patients
29 Occluded Aorta
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31 SMALLER INCISIONS: DECREASED PAIN/ QUICKER RECOVERY
32 Trans Atlantic Inter Society Consensus (TASC)
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35 The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg Jan;59(1)
36 SVS WIfI Wound Ischemia Foot Infection 0 none >0.8 1 mild moderate severe <0.4
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41 Bypass versus angioplasty in severe ischaemia of the leg Among 224 patients assigned to PTA, 217 underwent the procedure, immediate technical failure occurring in 43 (20 percent). Among 228 assigned to bypass surgery, 196 underwent the procedure. Adam DJ, Beard JD, Cleveland T, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005; 366:1925.
42 2011 WRITING GROUP MEMBERS, 2005 WRITING COMMITTEE MEMBERS, ACCF/AHA TASK FORCE MEMBERS ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2011; 124:2020.
43 ACC/AHA 2011 For patients that have an estimated life expectancy of two years or less, or those who do not have autogenous vein available as a conduit, balloon angioplasty is reasonable as the initial procedure, in selected patients, to improve distal blood flow.
44 ACC/AHA 2011 For patients with an estimated life expectancy of more than two years, and who have available autogenous vein conduit, a bypass surgery is reasonable to perform as the initial treatment to improve distal blood flow.
45 Vascular Exam Pulse Rt Lt Femoral artery Popliteal artery Dorsalis pedis artery -ve/mono 1+ Posterior tibial artery -ve/mono 1+ ABI
46 Angiogram with angioplasty
47 Angiogram Femoropopliteal Segment
48 Angiogram BTK lesion Arch of foot
49 Balloon Angioplasty Preballoon Postballoon
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51 Vascular Exam Pulse Rt Femoral artery 2+ Popliteal artery 2+ Dorsalis pedis artery 1+ Posterior tibial artery biphasic ABI noncompressible
52 Wound care
53 18 25 Jan 2017 Admit for CABG Post operation no complication
54 Conclusion Multidisciplinary Endocrinologist Cardiologist Nephrologist Orthopedist PM&R Nutritionist Surgeon Hyperbaric chamber Stem cell Etc.
55 Limb Salvage in Diabetic Ischemic Foot Kritaya Kritayakirana, MD, FACS Assistant Professor Chulalongkorn University April 30, 2017
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