Managing Conditions Resulting from Untreated Cardiometabolic Syndrome

Transcription

1 Managing Conditions Resulting from Untreated Cardiometabolic Syndrome Matthew P. Namanny DO, FACOS Vascular/Endovascular Surgery Saguaro Surgical/AZ Vascular Specialist Tucson Medical Center

2 Critical Limb Ischemia Peripheral Arterial Disease (PAD) PARTNERS study, JAMA 2003

3 Alarming Numbers PAD is a chronic, progressive, debilitating, systemic disease ~12 million Americans have PAD Increasing by 1 million/year 50-75% of people are undiagnosed By age % of people suffer from PAD 150,000 amputations are done per year Treating PAD can increase quality of life, functional status and possibly reduce CV risk PARTNERS study, JAMA 2003

4 Risk Factors for P.A.D. Lifestyle Smoking Obesity Health conditions Diabetes Cardiovascular disease Erectile dysfunction Chronic kidney disease Hypertension Hyperlipidemia Demographics Older age Black race More than half of the attributable risk of P.A.D. is due to smoking and diabetes Licensed from Shutterstock, 2010 The information provided in this presentation was created with monetary support from ev3 Endovascular, Inc.

5 PAD Remains an Intractable Clinical Challenge Just 4% of all PVD patients are treated interventionally 8-10 Million U.S. PVD Patients 2.5 Million Patients Diagnosed

6 Continuum of Care PAD; Progressive, Non-Curable, Life Threatening Medical Management Directional Atherectomy PTA Nitinol Stenting Covered Stents/ Heavy Metal Surgical Bypass Amputation Healthy Leg McKinsey; 275 pts- 68% 1yr patency Multilevel/ CLI Zeller; 84% (de novo)/ 54% Restenosis/ ISR Definitive-??? 800 pts., multicenter BIG 4: VIVA Meta-analysis; 33% 1 Yr Patency (sfa) Resilient (Bard); 38% Absolute; 37% Durability; 72% patency, 100cm+ stents Absolute 63%, 235 pts Sabeti et al., 22/71% patency. VIABRANT; 53% BM VS. 55% VB, CA++, 9+ Resilient; 80% Tasc A/B BASIL Data; 68%-1yr patency, 452 pts. 28% complication rate.

7 The PAD Guideline: Treatment Algorithm PAD Detection and Screening- ABI Immediate smoking cessation Treat hypertension: JNC-7 guidelines Treat lipids: NCEP ATP III guidelines Treat diabetes mellitus: HbA 1c less than 7% Antiplatelet therapy (ACE inhibition; Class IIb, LOE CLI Determination Wound Management Infection Control, etc) Angiography, CTA, MRA, ABI-TBI, Duplex US Directional/ Rotational Atherectomy Stents PTA Covered Stents Thrombectomy, Thrombolysis Surgery Bypass Grafts -Vein -Cryo Vein -PTFE Endarterectomy Surgical Amputation Healthy Leg Medical Therapy Endovascular Therapy Surgical Therapy Amputation Integrated care requires a partnership of vascular specialists (vascular medicine, cardiology, interventional radiology, nursing, podiatry, and others)

8 Classification System* * Dormandy, et al. J Vasc Surg. 2000;31(suppl):S1 S296. The content of this program was developed for Covidien to be distributed to customers for training purposes only. Do not further copy or distribute.

9 Critical Limb Ischemia Rest pain Pain on elevation of the foot for extended period Usually occurs at night Patient may sleep in the chair Tissue loss Non-healing ulcer Gangrene Extensive gangrene with infection (wet gangrene)

10 CLI Rutherford 4-6 category. European Consensus Document Ischemic rest pain requiring opiate analgesia. Ankle systolic pressure<50 mm Hg. Toe pressure <30 mm Hg. Ulceration or gangrene of toes or foot.

11 CLI

12 Clinical Signs of Limb Ischemia Licensed from Custom Medical Stock Photo & Mediscan, 2010 The information provided in this presentation was created with monetary support from ev3 Endovascular, Inc.

13 Key Components of Therapy Control pain Treat the wound Treat infection Treat comorbid medical conditions Assess vascular supply Inflow Infrainguinal vasculature Assess revascularization options and risk

14 Vascular Assessment Clinical Exam Non invasive Vascular Studies- Duplex, Segmental pressures, ABI, TCOM, etc. CTA/ MRA Angiography

15 Inflow Vessels

16 Type of Therapy Endovascular Open surgical Hybrid approach (Combined open and endovascular approach)

17 Endoluminal Therapy Offers Less Invasive Approaches, Thereby Justifying Intervention at Earlier Stages in the Symptom/Disease Complex

18 Balloon it Subintimally dissect it Stent it Cover it SFA Excise it Lace it Freeze it Spin it Jet it Remote it

19 Which do you prefer??

20 TYPE OF THERAPY Intervention/Endovascular Single segment occlusion or multi-segment with favorable lesions Minimal tissue loss or rest pain Poor or no surgical options Poor targets Poor conduit or no conduit Poor surgical candidate (ESRD, CAD, Obesity)

21 Surgery DECIDING ON THE TYPE OF THERAPY Not having this option available will cost some patients their limb Multi-segment occlusion or multi-segment stenosis with unfavorable lesions (eccentric with heavy calcification) Poor interventional outcome or interventional failure Significant tissue loss Good surgical options Good targets Good conduit

22 Endovascular Access Options Antegrade/Retrograde Femoral Artery Open or percutaneous. Popliteal Artery- US guided Trans-Pedal Access (Dorsalis Pedis and Posterior Tibial) Trans-Brachial- open or percutaneous.

23 Retrograde DP access 21G Micropuncture needle in right DP artery 4F Micropuncture sheath + Tuohy-Borst/Co-pilot in right DP artery

24 Treatment Zone Aorta-iliac Femoral-popliteal Tibial- BTK (below the knee). Pedal- BTA (below the ankle).

25 Endovascular P.A.D. Treatment Angioplasty Mechanism: Catheter-guided balloon Balloon dilation Plaque displacement into the artery wall Vessel stretch and expansion Licensed from A.D.A.M., 2010 The information provided in this presentation was created with monetary support from ev3 Endovascular, Inc.

26 Endovascular P.A.D. Treatment Stents and Stent-Grafts Mechanism: Balloon-expandable or self-expanding Plaque displacement into the artery wall Vessel stretch and expansion Indications: Prevent recoil of the artery wall Repair complications resulting from angioplasty Licensed from A.D.A.M. & Nucleus Medical Media, 2010 The information provided in this presentation was created with monetary support from ev3 Endovascular, Inc.

27 Endovascular P.A.D. Treatment Atherectomy Mechanism: Debulk plaque Cut Pulverize Shave Remove or excise plaque Types: Directional or excisional Rotational or orbital Photoablative (excimer laser) Source: Garcia et al. (2009) The information provided in this presentation was created with monetary support from ev3 Endovascular, Inc.

28 Turbohawk

29 Thrombectomy/Thrombolysis Mechanical thrombectomy Aspiration Maceration Pharmacological thrombolysis Infusion of TPA On-table therapies Arterial and venous

30 Case Study 49 year old female with end stage CHF on continuous dobutamine drip. In need of heart transplant or LVAD. Non-healing wounds of right leg at previous saphenous vein harvest sight with underlying PAD.

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35 Conclusions Endovascular Intervention is a crucial part in the management of PAD. New technology and maturing endovascular skill make it possible to treat increasingly complex lesions. At times these complex patients have limited treatment options, making endovascular intervention more attractive.

36 Future Drug Eluting Balloons/stents. IVUS based intervention.

37 Limb Salvage Program Tucson Medical Center Multidisciplinary Limb Salvage Team Vascular Surgery Podiatry Infectious Disease

38 TMC Limb Salvage Program Consult Initiated by ER docs. Admitting doc. Wound Care RN. Surrounding areas (324-4leg) Patient evaluated by Vascular and Podiatry and treatment carried out by appropriate team.

39 TMC Limb Salvage Program Goal- Early detection of PAD and lower extremity wounds to facilitate quicker treatment, adequate follow up, and ultimately prevent amputations.

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41 Contact Information Dr. Matthew P. Namanny cell office 6422 E. Speedway #150 Tucson, Arizona (520)