Angiosome revascularization strategies in real world practice: how much difference does it make?

Transcription

1 Angiosome revascularization strategies in real world practice: how much difference does it make? Peter A. Schneider, MD Kaiser Foundation Hospital Honolulu, Hawaii

2 Disclosure Peter A. Schneider... I have the following potential conflicts of interest to report: Scientific Advisory Board (non-paid): Cardinal, Abbott, Medtronic Royalty (modest): Cook Co-founder and Chief Medical Officer: Intact, Cagent Enter patients into studies: NIH, Bard, Gore, Medtronic, BSI, Silk Road (no financial relationship). VIVA Board member (nonprofit)

3 Angiosome Concept Does it work? YES How should it be used? Guide clinical decisions in specific scenarios Plays a role in fewer than half of CLI patients

4 Strategy for Critical Limb Ischemia Rest pain-r4 Minor tissue loss-r5 Major tissue loss-r6 Revasc. one level or more Can almost always fix with endo, Don t always need to fix tibials Fix all levels of disease, including tibials Young patient Good vein Cannot open correct angiosome Too sick No vein Focal occlusive dis Endo: Open more than 1 tibial Open tibial to correct angiosome with endo Open tibial to boundary artery Early definitive foot surgery Close follow-up versus bypass Bypass

5 Angiosome Revascularization Reduced Amputation Risk Spillerova et al. Eur J Vasc Endovasc Surg 2015;49:412

6 Biancari et al. Eir J Vasc Endovasc Surg 2014;47:517

7 Angiosome Revascularization Forest plot for effectiveness in wound healing Forest plot for effectiveness in limb salvage Biancari F. Eur J Vasc Endovasc Surg. 2014;47:

8 Old Teachings Must establish in-line flow to the foot Typically with bypass, we are looking for the best quality target blood vessel to work with. Limb Amputation or Clinical Failure Despite a Patent Bypass Study CLI Patients Results Goodney at al Ann Vasc Surg 2010;24:59 Simons et al. J Vasc Surg 2010;51:1419 Taylor et al J Vasc Surg 2009;50: bypass 8% amputation at one year, 17% of these had a patent bypass 1012 bypass 10% of those with a patent graft had no clinical improvement 361 bypass 316 PTA Survival, limb salvage, and ambulation for one year: 37% for PTA and 44% for bypass

9 We are taught that these are fully anastomotic arteries. When the pedal arch is patent, the need for direct angiosomal revasc is diminshed or negated.

10 Diabetes: Value of Angiosome Concept Compartmentalized flow in the foot. We need targeted revascularization.

11 Isolated Below-the-knee Lesions Iida et al. J Vasc Surg 2012;55:363

12 Problems with Angiosome Concept Variability in angiosome size/location among patients. Variability in collateral connections between angiosomes. Intact pedal arch, more likely in non-diabetics. Rutherford 4-no tissue loss, revasc any vessel. Rutherford 6-crosses angiosomes, revasc all arteries. Lesion above the ankle. Superficial ulceration (<10mm in diameter), esp. if toe pressure >50mmHg after PTA.

13 Angiosomal Anatomy Medial plantar artery Attinger. Plast Reconstr Surg 2006;117:261

14 161 cases of CLI-University of Helsinki Spilllerova et al. Ann Vasc Surg 2016;30:270

15 Rashid et al. J Vasc Surg 2013;57:1219. In a study of bypass, a patent pedal arch was more important than the angiosome.

16 Direct Revascularization in Bypass Patients Wound healing was faster. Limb salvage was the same. Angiosome helpful in about half the patients. Only about 1/3 of wounds fit neatly into a specific angiosome. Kret et al. J Vasc Surg 2014;59:121

17 Better Wound Healing with Direct Revascularization No difference in limb salvage Iida et al. J Endovasc Ther 2014;21:607

18 Iida et al. Eur J Vasc Endovasc Surg 2013;46:575

19 Bypass PTA Spillerova et al. Eur J Vasc Endovasc Surg 2015;49:412

20 Direct better than Indirect for would healing xx Indirect with good collaterals as good as Direct for limb salvage Zheng et al. Ann Vasc Surg 2016;32:41

21 Angiosome Revascularization Conclusion An opportunity for targeted therapy. Healing is more likely and faster after direct revasc of the correct angiosome. Angiosome concept helps explain some of the variability in results of revasc for CLI, especially in diabetics with compartmentalized pedal circulation. Angiosome concept helps guide therapy in some patients.

22 Angiosome revascularization strategies in real world practice: how much difference does it make? Peter A. Schneider, MD Kaiser Foundation Hospital Honolulu, Hawaii