Critical Limb Ischemia A Collaborative Approach to Patient Care. Christopher LeSar, MD Vascular Institute of Chattanooga July 28, 2017
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1 Critical Limb Ischemia A Collaborative Approach to Patient Care Christopher LeSar, MD Vascular Institute of Chattanooga July 28, 2017
2 Surgeons idea
3 Surgeons idea
4 represents the final stage of peripheral vascular disease progression
5 Clinical Responsibility
6 WOUND GRADE AMP ISCHEMIA INFECTION
7 QUESTION #1 How Threatened is the Limb?
8
9 Which Foot Is Ischemic? Right: Pain Worse at Night / Rubor Left: Sudden Onset Pain In the Good Leg
10 Which Foot Is Ischemic? Right: Chronic Ischemia Left: Acute Ischemia
11 CLI Clinical Assessment ACUTE ISCHEMIA
12 Pulse Exam
13 Neuromotor Exam 1x Speed 56 y/o Female < 24h Sudden Pain in Left leg Poor movement of toes on Left
14 Neurosensory Exam 4x Speed 56 y/o Female < 24h Sudden Pain in Left leg Poor Sensation from Left Knee to Toes
15 Severity of Limb Ischemia Class 1: The limb is viable even without therapeutic intervention. Class 2: The limb is threatened and requires revascularization for salvage. Class 3: The limb is irreversibly ischemic and salvage is not possible. Rutherford RB, J Vasc Surg. 1997; 26:
16 Severity of Limb Ischemia Class 1: The limb is viable even without therapeutic intervention. Class 2: The limb is threatened and requires revascularization for salvage. Class 3: The limb is irreversibly ischemic and salvage is not possible. Rutherford RB, J Vasc Surg. 1997; 26:
17 Severity of Limb Ischemia Class 1: The limb is viable even without therapeutic intervention. Class 2: The limb is threatened and requires revascularization for salvage. Class 3: The limb is irreversibly ischemic and salvage is not possible. Rutherford RB, J Vasc Surg. 1997; 26:
18 Algorithm Clinical Ischemia Class 1 Class 2A Class 2B Class 3 Revascularization Elective Therapy Semi-Elective Therapy Urgent Therapy Major Amputation
19 Which Foot Is Ischemic? Right: Pain Worse at Night / Rubor Left: Sudden Onset Pain In the Good Leg
20 CLI Clinical Assessment CHRONIC ISCHEMIA
21 WOUND GRADE AMP ISCHEMIA INFECTION
22 PI AA March 2012 Page 22 of 55 Severity of Limb Ischemia: Fontaine and Rutherford Classification Schemes Circulation 2006;113;e463-e465
23 ischemia. Limb salvage is depend damage and angiosomal perfusion Rutherford 4
24 Rutherford 5
25 Rutherford 6
26 WOUND GRADE AMP ISCHEMIA INFECTION
27
28 WOUND GRADE AMP ISCHEMIA INFECTION
29
30 WOUND GRADE AMP ISCHEMIA INFECTION
31
32 WOUND GRADE ISCHEMIA AMP DIABETES INFECTION
33
34
35 QUESTION #1 How Threatened is the Limb?
36 QUESTION #1 How Threatened is the Limb? Degree of Ischemia and Infection!
37 QUESTION #2 What determines limb salvage in CLI?
38 Amputation First? 417 patients in a Medicare population with lower leg CLI evaluated for amputation Primary Amputation 67% Infrainguinal Bypass 23% Angioplasty 10% Complications: 80% wound, 78% MI, and 81% Stroke: Primary Amputation Only 16% had an Angiogram prior to Primary Amputation Allie DE, et al. EuroIntervention. 2005;1:75-84.
39 Compartmentalized Pedal Flow Stenosis Images courtesy of Peter Schneider
40 Angiosome Perfusion
41 BTK Today: The Angiosome Concept An angiosome is an anatomic unit of tissue fed by a source artery Six angiosomes feed the foot Targeted therapy of the artery to the ischemic wound. Maximize ulcer/wound healing Sometimes there is Isolated Arterial Perfusion Dean SO. Defining Angiosome Anatomy for Reperfusion Decisions. (VIVO, Chalk Talk). Wednesday, October 20, 2010.
42 Lateral Plantar Artery Attinger CE, et al. Plast Reconstr Surg. 2006;17(7 Suppl):261S-293S.
43 Medial Plantar Artery Variability Attinger CE, et al. Plast Reconstr Surg. 2006;17(7 Suppl):261S-293S.
44 WOUND GRADE AMP ISCHEMIA INFECTION
45 WET GANGRENE 12 HOURS LATER
46 65 y/o WF with Rapid progression of Gangrene Right Foot PMH: DM, HTN, CAD Rutherford 6 Wet Gangrene
47 No Surgical Bypass Options Classic Answer: BKA (Life Saving) Subintimal Dissection PTA Surgical Debridment of Infection
48 MICRO PUNCTURE ACCESS OCCLUDED POSTERIOR TIBIAL
49 Tibial Retrograde Transluminal Angioplasty
50 PI AA March 2012 Page 50 of 56
51 PI AA March 2012 Page 51 of 56
52 RECONSTRUCTION OF BOTH ANTERIOR AND PORTERIOR CIRCULATIONS OF THE FOOT
53 RECONSTRUCTION OF BOTH ANTERIOR AND PORTERIOR CIRCULATIONS OF THE FOOT ANGIOSOME CONCEPT
54 TWO WEEKS SIX WEEKS
55 WOUND GRADE ISCHEMIA AMP PREVENTION INFECTION
56 Case 1 65 y/o Ischemic ulceration Right foot PMH: HTN, CAD, Dyslipidemia Left AKA SH: Former significant smoking PE: Palp Fem pulse, no pop or tibial
57
58
59
60 Distal SFA 95% Stenosis Primary Angioplasty And Stent
61 Atherectomy Angioplasty 2.5 x 150 EN-1262.A
62 EN-1262.A
63 EN-1262.A
64 Orbital Atherectomy 1.25 Micro Crown Angioplasty 2.0 x 150 mm
65 Final Final
66 Healing wounds Two weeks post op
67 Four Weeks
68 CRITICAL LIMB SPECIALIST HISTORY & PHYSICAL (PULSE EXAM) LIMB SALVAGE ANGIOSOME CONCEPT ANGIOGRAM CAPABILITY
69 Case 2 59 y/o WF with distal embolization Left 1 st, 2 nd, 3 rd toes x 6 months PMH: HTN, PVD, S/P bilateral kissing iliac stents 12 months prior SH: Significant continued smoking ½ pack/day PE: Palpable Left Fem, Pop, PT, DP
70 1 Week Post Op Embolization Syndrome S/P Bilateral Kissing Iliac Stents Painful Blue Toes
71 EN-1262.A
72 3 Months Post Op Embolization Syndrome Intense Fire-Like Pain with Rubor Pain Worse at Night
73 AP VIEW LEFT LATERAL OBLIQUE TIBIALS
74 LEFT LATERAL OBLIQUE TIBIALS RIGHT LATERAL OBLIQUE FOOT
75 AP/CRANIAL VIEW FOOT
76 Orbital Atherectomy 1.25 Micro Crown Angioplasty 1.5 mm x 10 cm
77 EN-1262.A
78 EN-1262.A
79
80 CRITICAL LIMB SPECIALIST HISTORY & PHYSICAL (PULSE EXAM) LIMB SALVAGE ANGIOSOME CONCEPT ANGIOGRAM CAPABILITY
81 Case 3 The Test 47 y/o WM with Pain and Numbness in Right Toes x 2 Months PMH: PVD, Aortic Occlusion S/P Aorto-Bi-Fem Bypass SH: Significant former smoking PE: Palpable Right Fem, Pop, PT, DP LAB: Zero Toe Pressure
82
83 Rest Pain with Numbness of Toes Critical DPA Stenosis with a weak LPA
84 LATERAL VIEW AP/CRANIAL VIEW
85 Co-Dominant Flow Immediate Pain and Numbness Improvment
86 CRITICAL LIMB SPECIALIST HISTORY & PHYSICAL (PULSE EXAM) LIMB SALVAGE ANGIOSOME CONCEPT ANGIOGRAM CAPABILITY
87 Case 4 69 y/o White Female Gangrene L 2 nd toe PMH: HTN, CAD, Dyslipidemia SH: Former significant smoking PE: Palp Fem pulse, pop, no tibial pulses
88
89
90 CSI 1.25s PTA 3 x 4
91 CSI 1.25s
92 PTA 2 x4
93 Two weeks post-op Four weeks post-op
94 CRITICAL LIMB SPECIALIST HISTORY & PHYSICAL (PULSE EXAM) LIMB SALVAGE ANGIOSOME CONCEPT ANGIOGRAM CAPABILITY
95 Pedal Retrograde Subintimal Angioplasty
96 REST PAIN NEAR CONSTANT INABILITY TO SLEEP RUTHEFORD 4
97 PERONEAL OUTFLOW ONLY Two weeks post-op Four weeks post-op POOR CONNECTION PEDAL ARCH
98 RETROPEDAL ACCESS ONLY OPTION
99 ULTRASOUND ACCESS
100 SUBINTIMAL DISSECTION Two weeks post-op Four weeks post-op RETROPEDAL ANGIOGRAM
101 Angioplasty 2.5 x 3 x 210 PI AA March 2012 Page 101 of 56
102
103 Vascular Surgery Options
104 Endovascular Options
105 Hybrid: Surgical Bypass
106
107 79 y/o WM with Pain and Numbness in Feet x 2 months R>L PMH: DM, HTN, CAD c CABGx5 Rutherford 4 Rest Pain
108 POPLITEAL OCCLUSION
109 ATHERECTOMY ANGIOPLASTY STENT REPAIR
110 TP TRUNK OCCLUSION RETROGRADE PTA ACCESS
111 PTA DOMINANT OUTFLOW NOTED PUNCTURE
112 NEW WOUND FROM TEGADERM DRESSING PUNCTURE POST OP DAY 3 NOW RUTHERFORD 5!
113 INCISION RIGHT KNEE
114 S/P CABG with Bilateral GSV Harvest, LSV with Superficial Chronic Phlebitis SHOULDER Harvest Right Cephalic Vein
115 Posterior Tibial Popliteal Peroneal Occluded TP Trunk
116 Reversed Right Cephalic Vein Pop to TP Trunk Bypass
117 Reversed Right Cephalic Vein Pop to TP Trunk Bypass
118 POST OP BYPASS DAY 7 WOUND STARTING TO HEAL
119 "How do we as a medical community get ahead of and manage this disease for patients."
120 "How do we as a medical community get ahead of and manage this disease for patients."
121 Community Network for CLI
122 Interventionalists Primary Care CLI Endocrine Wound Care Vascular Medicine Podiatric Specialists Infectious Disease Emergency Medicine Cardiology
123
124
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