CLI Therapy- LINCed Multi disciplinary discussions on CLI

Transcription

1 CLI Therapy- LINCed Multi disciplinary discussions on CLI Critical limb ischemia and managing the infected wound Michiel Schreve North West Clinics Alkmaar, The Netherlands

2 Disclosure Speaker name: Michiel Schreve I have the following potential conflicts of interest to report: X Consulting (Vascular Insight, Limflow) Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest

3 Critical Limb Ischemia (CLI) Defined (1982): an ankle pressure (AP) <40 mm Hg in the presence of rest pain and <60 mm Hg in the presence of tissue necrosis. It was generally agreed that diabetic patients who have a varied clinical picture of neuropathy, ischemia and sepsis make definition even more difficult and it is desirable that these patients be excluded or should be clearly defined as a separate category to allow the analysis of the results in the nondiabetic patients.

4 women 46 Rest pain R5/Dry necrosis BTK disease embolic lesion aorta Case 1

5 Revascularisation Amputation Healing No infection Case 1

6 World of Today CLI and diabetes cannot be seperated Studies on CLI; 60% diabetes (BASIL trial, PREVENT III) Specialized vascular centers 70-80% diabetes WHO projects a 170% growth of diabetes by 2025

7 Diabetic patients are at risk for severe foot infection due to neuropathic ulcers The European Study Group on Diabetes and the Lower Extremity (Eurodiale) 575 patients; with a diabetic foot ulcer 28% amputated Predictors 2015

8 Independent risk factors periwound edema foul smell deep ulcer pretibial edema Fever and elevated C-reactive protein. The presence of PAOD is a independent risk factor for amputation with an odds ratio of 3.

9 Our patients are the worst They have Critical limb ischemia in combination with diabetic ulcer (neuroischemic) 50% of the diabetic ulcers = neuroischemic ulcers Half of them end up with an amputation! Treat ischemia and infection

10 The Dutch Guideline on diabetic foot Multidisciplinair team: patient and the foot vascular surgeon, endocrinologist, rehabilitation specialist, cast technician, shoe technician and a podiatrist The 5-year mortality is 50% to 60%, with coronary events and strokes accounting for at least 70% of the deaths Recurrence of ulcers is 40% in the first year* * Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376:

11 THE SVS WIfI CLASSIFICATION SYSTEM limb perfusion, wound depth and presence and extent of infection The WIfI is intended to define the disease Predicts amputation Not designed to dictate treatment method

12 How do you prioritize revascularisation vs. treatment of infection in patients with CLI No Studies Guidelines yes

13 Male 70 CLI /Diabetes COPD Gangreen Osteomyelitis 1-3 antibiotics CASE 2 BTK vessel disease

14 R5 Wound (WIfI: W2I3fI2) moderate infection osteomyelitis 1. revascularize first 2. amputate second prolonged antibiotics (osteomyelitis)

15 ATA failed POBA Posterior PT 2 wire Sterling

16 Amputation of the forefoot Culture (guideline): biopsy (tissue/bone) Swab (deep or Levine) Antibiotics (guideline): Started emperical Severe infection 2-4 weeks Osteomyelitis 2-6 weeks Multidisciplinair Woundcare team

17 1.Hinchli e RJ, Brownrigg JR, Apelqvist J, et al; International Working Group on the Diabetic Foot. IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes Metab Res Rev. 2016;32(Suppl 1): International Working Group of Diabetes Foot (IWGDF/PEDIS) Any infected ulcer should be debrided + antibiotics Aggresive surgical treatment Revascularisation when needed Signs of sepsis: start SIRS and surgical treatment first

18 Case 3 65 Male Diabetes Renal Failure: hemodialysis 1 st Toe Amputation Sepsis and suspicious of Necrotizing Fasciitis Tachycardia WBC 25k Courtesy of S. KUM

19 25/8/17 Sepsis treatment and Immediate disarticulation and Washout Tissue and Bone biopsy (culture) Emperic Intravenous Antibiotics

20 BTK/ Multipele stenosis

21 R6 Wound (W3l3fl3) Sepsis + Necrotizing Fasciitis + Dialysis dependent 1. Treatment sepsis, aggressive surgical debridement 2. Revascularization and woundcare

22 Plantar loop (PT 2 wire, Armada XT 2x20) POBA ATA/PTA

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24 28/8/17-13/9/17 Multiple Debridement + Pulse Lavage Tissue Culture: Mixed Growth Enteric Organisms Antibiotics continued

25 6/10/17 VAC therapie

26 20/10/17 Split Skin Graft

27 27/10/17 came in with wet and infected wounds SSG not taken

28 secondary healing Plantar epithelizing

29 21/12/17 Pus along plantar and dorsum osteomyelitis of the midbones Staph Aureus bacteremia

30 Guillotine Amputation 11/1/18 Desai Y, Robbs JV, Keenan JP. Staged below-knee amputation for septic peripheral lesions due to ischaemia. Br J Surg. 1986; 73(5): McIntyre KE, Bailey SA, Malone JM, Goldstone J. Guillotine amputation in the treatment of nonsalvageable lower-extremity infections. Arch Surg. 1984; 119(4): Fearon J, Campbell DR, Hoar CS, Gibbons GW, Rowbotham JL, Wheelock FC. Improved results with diabetic below-knee amputations. Arch Surg. 1985; 120(7): Kernek CB, Rozzi WB. Simplified two-stage below-knee amputation for unsalvageable diabetic foot infections. Clin Orthop Rel Res. 1990; 261:

31 17/1/18 Formal BKA/Burgess We got the blood in, but not the infection out

32 Conclusion Diabetes is a worldwide problem and rising CLI and diabetes is a bad combination Multidisciplinairy team approach Sepsis: agressive SIRS and surgical treatment Culture by biopsy (tissue or bone) Prolonged antibiotics (culture)

33 Thank you for your attention Michiel Schreve Alkmaar, The Netherlands

34 CLI Therapy- LINCed Multi disciplinary discussions on CLI Critical limb ischemia and managing the infected wound Michiel Schreve North West Clinics Alkmaar, The Netherlands