Wound and surgery-guided revascularization & flow-guided surgery: the multidisciplinary approach to limb salvage
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1 Wound and surgery-guided revascularization & flow-guided surgery: the multidisciplinary approach to limb salvage Vincenzo Foppa, 1462 The miracle of the salvaged foot Cappella Portinari, S. Eustorgio Church Milan, Italy
2 Disclosure Roberto Ferraresi, MD In the last 2 years I have the following potential conflicts of interest to report: Consultant: Medtronic, Abbott, Boston Scientific, Contract Medical International, Cook, Asahi, Ivascular, Biotronic, Limflow, Spectranetics, Shire, Kardia, Astra Zeneca, Orbus, Bard Virtual shareholder: Limflow
3 1. Tissue-guided revascularization 2. Flow-guided surgery: Complete revascularization Partial revascularization SAD pts: the tension-free surgery concept
4 Recognize the distribution 1 pattern of the foot Absence of the pedalplantar loop 0.2% balanced 79.1% dominant DPA 0.4% dominant LPA 13.2% tarsal loop 7.2%
5 Recognize the wound- 2 related artery
6 Conclusion DR appears to result in improved wound healing and limb salvage rates compared with IR, with no effect on mortality or re-intervention rates. When possible, these low quality data suggest DR should be undertaken in preference to IR. According to this concept, it seems reasonable to pursue belowthe-ankle arteries angioplasty in order to give direct flow to the wound!
7 3 Recognize the role of collateral vessels The value of an angiosome-oriented revascularization is inversely related to the function of collateral vessels
8 3 Recognize the role of collateral vessels SAD with/without BAD Collateral vessels are generally involved failure of the foot distribution system
9 4 Pursue a complete rev. Open BTK vessels Limb salvage 0 56% 1 73% 2 80% 3 83% 1 better than better than 1 PTA of tibial arteries had a better outcome than PTA of the peroneal artery alone
10 4 Pursue a complete rev. Results: The wound(s) interfered with one angiosome in only 24.0% cases. Conclusions: In CLI, the tissue lesion affects several angiosomes in the majority of the cases.
11 1. Recognize foot vessel anatomy & disease 2. Identify reasonable targets of revascularization 3. Try to give as much as possible blood flow to the wound! The foot surgeon will thank!
12 1. Tissue-guided Rev.: the angiosome concept 2. Flow-guided surgery: Complete revascularization Partial revascularization SAD pts: the tension-free surgery concept
13
14 When you have a complete blood supply everything is surgically possible
15 1. Tissue-guided Rev.: the angiosome concept 2. Flow-guided surgery: Complete revascularization Partial revascularization SAD pts: the tension-free surgery concept
16 Pure dorsal blood supply due to anatomical or technical reason
17 Pure plantar blood supply due to anatomical or technical reason
18
19
20
21 In pts with partial rev. foot surgery must be tailored on the vascular supply, respecting the main vessel!
22 1. Tissue-guided Rev.: the angiosome concept 2. Flow-guided surgery: Complete revascularization Partial revascularization SAD pts: the tension-free surgery concept
23 1 Normal pt
24 2 SAD pt
25 3 Advanced SAD pt
26 1 2 3
27 1 2 3
28 1 2 3
29 1 2 3
30
31
32 SAD can jeopardize the outcome of foot surgery. Second intention, tension free surgery could be an option to improve outcome in SAD-CLI pts
33 Wound and surgery-guided revascularization & flow-guided surgery: the multidisciplinary approach to limb salvage Vincenzo Foppa, 1462 The miracle of the salvaged foot Cappella Portinari, S. Eustorgio Church Milan, Italy
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Potential Conflicts of Interest
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