Surgical Options for revascularisation P E T E R S U B R A M A N I A M

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1 Surgical Options for revascularisation P E T E R S U B R A M A N I A M

2 The goal Treat pain Heal ulcer Preserve limb Preserve life

3 The options Conservative Endovascular Surgical bypass Primary amputation

4 Decision making Severity of CLI symptoms and extent of tissue loss Fitness of patient for intervention Ambulatory status Likely life expectancy Arterial anatomy intervention options

5 CLI and risk of CV events CLI as an indication of extensive atherosclerotic load % risk of secondary events post intervention (CV events, death, major amputation)

6 PREVENT111 Randomised, prospective (EF2 v surgical bypass) of CLI 64% diabetic ; 75% tissue loss Early failure 5%; 1 year patency 51%; secondary patency 82%; limb salvage 88% and survival 84% Predictors for poor outcome Vein < 3mm Non single vein conduit Afro-american

7 Challenges of distal bypass

8 Surgical treatment of the diabetic foot prompt incision, drainage, and débridement including partial open toe, ray, or forefoot amputation. Even in the presence of foot infection, pedal bypass can be performed safely as long as invasive sepsis is controlled before surgery

9 The conduit pre op preparation Use of ultrasound to evaluate calibre of vein tourniquet; stand patient Internal diameter Compressibility Sclerosis or varicose segments Select best autogenous conduit Map and mark the conduit placement of incision for vein harvest to minimise undermining of the skin

10 The conduit intraoperative Gentle handling during harvesting Endothelial damage and natural loss Ischemic time Careful distension of conduit Heparinised saline papaverine Tunnelling without kink or distortion of conduit

11 The conduit post implantation Completion angiography Confirms graft patency Identifies stenosis Confirms run-off arterial bed Intra operative duplex evaluation More sensitive Predictive of early graft failure PSV <45 cm/s; ratio > 2

12 The conduit post operative management Peroneal run-off? Use of perfusion pressure assessment Duplex to confirm patency of graft Anticoagulation? Anti-platelet therapy

13 Conduit options Contralateral GSV Arm vein bypass single segment or spliced Prosthetic with modification e.g. Miller cuff

14 R. L. V A R C O E, W. C H E E, P. S U B R A M A N I A M, D. R O A C H, G. L. B E N V E N I S T E, R. A. F I T R I D G E A R M V E I N B Y P A S S G R A F T S A S A L A S T A U T O G E N O U S O P T I O N F O R I N F R A I N G U I N A L B Y P A S S S U R G E R Y : T H E Y A R E W O R T H T H E E F F O R T E U R O P E A N J O U R N A L O F V A S C U L A R A N D E N D O V A S C U L A R S U R G E R Y, ; 3 3 ( 6 ) :

15 Anastomosis Distal versus proximal as the first anastomosis to perform Length of conduit Twisting of conduit Vessel control Tourniquet Balloon or dilator occlusion Atraumatic clamps Tunnelling Anatomic versus superficial Parachuting Endarterectomy Target vessel Visualising the lumen

16 Surgical strategies Length of bypass Shorter grafts have better patency Improve inflow by pre-bypass angioplasty or stenting Use distal SFA or popliteal as take-off site for graft

17 Post operative care Keep the graft flowing Early graft surveillance Vein graft surveillance programme Treat the foot Continued foot and ulcer care Use of negative pressure dressings Keep the patient alive Statin (increases 1 year survival rates*) Anti platelet agents Treatment of hypertension and diabetes# to target goals

18 Conclusion Technical Aspects Selection of autogenous conduit Appropriate inflow out flow target vessels Careful dissection and tunnelling Wound closure under zero tension

19 diabetes is not a risk factor for vein graft failure; diabetes is associated with increased risk for both long-term mortality and limb loss in the patient with CLI.

20 Achieving success Aggressive revascularization to tibial/pedal targets Multidisciplinary wound and foot care long-term surveillance in management of the patient with diabetes with a dysvascular limb

21 Conclusion non technical Experienced clinical judgement Technical precision Fastidious post-operative care Surveillance programme