Current Vascular and Endovascular Management in Diabetic Vasculopathy
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1 Current Vascular and Endovascular Management in Diabetic Vasculopathy Yang-Jin Park Associate professor Vascular Surgery, Samsung Medical Center Sungkyunkwan University School of Medicine
2 Peripheral artery disease (PAD) Chronic lower extremity ischemia Manifestations of PAD (degree of muscle ischemia) Asymptomatic Intermittent claudication (IC) Critical limb ischemia (CLI) Prevalence of symptomatic PAD
3 Stages of chronic limb ischemia Critical limb ischemia (CLI)
4 Risk factors for symptomatic PAD
5 PAD in diabetes More common (~x2) intermittent claudication PAD in DM 26% increased risk of PAD / 1% increase HbA1c Insulin resistance More aggressive compared to non-diabetes early large-vessel involvement major amputation risk : x5-10 Foot ulcers and infections Peripheral neuropathy resistance to infection Aggressive control of blood glucose levels HbA1c <7.0% or as close to 6% as possible
6 Characteristics of diabetes vasculopathy Diffuse multilevel involvement Infragenicular arteries Heavy calcification Poor collateral developments Microangiopathy Macroangiopathy
7 Noninvasive Diagnosis of PAD Non-invasive vascular laboratory( 혈관검사실 ) ABI (ankle-brachia index) Toe pressure or toe-brachial index (TBI) Exercise treadmill test Segmental limb pressure Pulse volume recording (PVR) Digital PPG
8 ABI (Ankle-brachial index) (Hiatt WR. NEJM 2001)
9 Toe pressure & toe-brachial index Long-standing diabetes, renal failure Incompressible tibial artery Falsely high systolic pressure Non-compressible Ankle pressure 250mmHg ABI >1.40 Toe pressure Useful in DM 30mmHg less than ankle pressure <40mmHg : impaired wound healing Toe-brachial index (TBI) <0.70 Limitation : inflammatory lesions, ulceration, tissue loss
10 Radiologic diagnostic modality Duplex scan Easy to perform : accessibility No contrast media and radiation Operator-dependent Calcium in diabetes MR angiography No radiation Gadolinium toxicity: nephrogenic systemic fibrosis Overestimate stenosis CT angiography Most-frequently used in Korea : cheap, popular, quick Radiation and contrast media use Calcium in diabetes Digital subtraction angiography Most accurate in diabetes Radiation and contrast media use Invasive : femoral puncture Pre-intervention purpose : intention-to-treat
11 Risk factor modification Smoking cessation Treatment of PAD Claudicants LDL cholesterol < 100 mg/dl LDL < 70 mg/dl if high risk (eg. DM) HbA1c < 7.0% BP < 140/90 mmhg BP < 130/80 mmhg if diabetic or renal disease Antiplatelet therapy
12 Treatment of PAD Claudicants Supervised exercise therapy Treadmill or track walking Sufficient intensity to bring on claudication, followed by rest Over the course of a min session 3 times a week for 3 months Pharmacotherapy Cilostazol (Pletaal): 1 st drugs Pentoxifylline (Trental) Prostaglandin analogues
13 Critical Limb Ischemia in diabetes Chracterized by Occlusive rather stenotic lesions Diffuse, long lesions Multilevel lesions Infrapopliteal lesions Most PAD in diabetes
14 1-Year Outcome of CLI
15 Survival of Amputees Subramanian B, Anesth Analg 2005;100:1241-7
16 Indications or goals of below-the-knee (BTK) revascularization Indications Patients with CLI for limb salvage Not simple intermittent claudication Clinical goals Limb salvage Better wound healing Pain relief Early mobilization
17 Primary amputation vs. Revascularization Lower Extremity Grading System (LEGS) Score Arteriographic findings Stenosis or occlusion Lesion length Presentation Claudication or critical limb ischemia Functional status Ambulatory or non-ambulatory Comorbidities Obesity, CAD, old age Technical factors Redo-procedure, available vein conduit, target vessel status, infection Recommended treatment Low score : open surgery Intermediate score : endovascular intervention High score : primary amputation
18 WIFI Classification for Risk of Amputation
19 Vascular anatomy of leg
20 Angiosome concept
21 Revascularization option of PAD Endovascular intervention Surgical bypass Angiogenesis Gene therapy Stem cell
22 Endovascular Therapy for Limb Salvage Relatively new and continually evolving technology Recent advances: DES, DCB hold promise Potential advantages Less invasive: mortality and morbidity (?) Fast recovery Potential disadvantage Reduced efficacy: hemodynamics, durability Risk of limb deterioration May affect surgical options Cost: frequent repeated treatments, symptom-free intervals Outcomes poor for more extensive disease, multi-level disease, major tissue loss, possibly diabetics
23 Infrainguinal Bypass Surgery for CLI Bypass with autogenous vein is the gold standard Results well documented in hundreds of reports: anecdotal > retrospective > randomized trials Versatile: results in complex situations (anatomic, patient related) well established Low mortality, good durability BUT-there are limitations and risks: Wound and other complications Prolonged recovery Vein quality and availability Technically demanding procedures Outcomes poorer for suboptimal conduit, higher medical risk
24 2011 ESC recommendation for PAD Critical Limb Ischemia
25 J Vasc Surg 2009;50:54-60
26 Angioplasty is not durable 15% need BPG 26% need redo 1 yr 41% failure rate J Vasc Surg 2008;48:128-36
27 J Vasc Surg 2011.;54:730-6
28 Cost-effectiveness Best: Bypass with interventional revisions Endovascular-first is not costeffective Must identify cost-drivers! Slow wound healing Procedural costs J Vasc Surg 2012;56:
29 Semin Vasc Surg 25: , 2012
30 Wound healing: Size and Time to healing Semin Vasc Surg 25: , 2012
31 Factors influencing wound healing of critical ischemic foot after bypass surgery: is the angiosome important in selecting bypass target artery? 249 distal bypasses: 81% diabetics, 49% ESRD Healing rate in indirect revascularization was slower than in direct revascularization, especially in ESRD patients (P<0.001) No difference after propensity scoring (P=0.185) Conclusion: The angiosome concept seems unimportant, at least in non-esrd cases Azuma, Eur J Vasc Endovasc Surg, 2012
32 CASE 1 F/61 CC : infected ulcer, rt. foot (1WA) BHx: Known DM patient with insulin (40y, type 1) s/p rt. 4-5 toe amputation d/t trauma (40YA)
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35 Femoral angio via 5F sheath BTK angio via 4F shuttle
36 Ankle AP Ankle lateral
37 True luminal passage using V18 + microcatheter change to 0.14GW & BAP with 2mm*120mm
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40 BAP with 2.5-3mm*210mm
41 Final angiography
42 Post-intervention course IV antibiotics Wound culture : MRCNS, Pseudomonas,Citrobacter, Corynebacterium Vancomycin, Tazocin Daily I & D at OR Ray amputation at POD#7 Clean wound and well-healed
43 CASE 2 M/72 DM CRF on HD HTN DM foot at 5 th toe
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58 CASE 3 M/81, Rt. 2 nd toe unhealing wound and pain HTN, s/p CABG, CRF on HD Un-healing wound and pain at Rt. 2 nd toe for 4 months
59 DSA
60 Infrapop-DPA bypass
61 Follow-up Duplex scan
62 CASE 4 M/81 DM CRF on HD HTN Unhealing wound at 1 st toe, right endovascular intervention : failed aggravated wound infection after minor trauma
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65 Updated 2017 ESC guideline for PAD
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67 Summary All diabetic patients with ischemic symptom or unhealing ulceration objective testing for PAD Early identification of PAD at risk Essential for limb salvage Multidisciplinary approach Organized and systematic management for PAD in diabetics Diabetic foot clinic
68 Thank you for your attention
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