Infection/ischaemia/amputation: how to build a multidisciplinary center for limb salvage
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1 Infection/ischaemia/amputation: how to build a multidisciplinary center for limb salvage Roberto Ferraresi Peripheral Interventional Unit Bergamo Italy ferraresi.md@gmail.com
2 Disclosure Roberto Ferraresi, MD I have the following potential conflicts of interest to report: consulting, travel reimbursement, teaching courses, training, proctoring: Medtronic, Boston Scientific, Abbott, LimFlow, Terumo, Cook, Biotronik, Asahi, Shire, Kardia, Orbus
3 1. The big bag of CLI 1. Medical team 2. Multidisciplinary team 2. Toe team 3. Flow team 3. People & protocols it
4 TASC II Critical limb ischemia is a bag in which we put every patient with PAD and foot suffering
5 Causes of PAD Foot lesion CLI Patient status Obstruction pattern
6 CLI is a complex disorder. We can treat it only pursuing a patient-centric approach in a multidisciplinary team
7 1. The big bag of CLI 1. Medical team 2. Multidisciplinary team 2. Toe team 3. Flow team 3. People & protocols it
8 TASC II In our CLI pts >70% have a history of CAD and >30% cerebrovascular disease Internal medicine expertise Proper management of comorbidities DOPPS Study The prevalence of CLI in ESRD-HD pts ranges between 4-17% In our CLI pts: 30% are ESRD-HD
9 Internal medicine expertise Proper management of comorbidities: Proper clinical, life expectancy & QoL evaluation Overall survival remains poor in CLI pts regardless of the procedure-related success. Patients do not always experience significant gains in their QoL after limb salvage interventions, despite reasonable graft patency, amputation-free survival, and limb salvage rates. We should maximizes patient-centered outcomes.
10 The medical team plays a pivotal role in CLI treatment guiding us in tailoring every treatment on the patient
11 1. The big bag of CLI 1. Medical team 2. Multidisciplinary team 2. Toe team 3. Flow team 3. People & protocols
12 Foot surgical & orthopedic management Infection surgery: wet gangrene, abscess, phlegmon. Curative surgery Debridement Negative wound pressure therapy Dermal Substitute Skin graft Fasciocutaneous graft Flaps Corrective surgery of deformities Charcot foot surgery
13 A strong toe team, able to use every type of wound treatment, is essential in achieving success
14 1. The big bag of CLI 1. Medical team 2. Multidisciplinary team 2. Toe team 3. Flow team 3. People & protocols it
15 Italian consensus document on PAD treatment in diabetics
16 CLI Long lesions Short lesions 4 Y 1 N Angioplasty first strategy Bypass first strategy
17 Open & Endo approaches are complementary and must be choosen according to a patientcentered strategy
18 1. The big bag of CLI 1. Medical team 2. Multidisciplinary team 2. Toe team 3. Flow team 3. People & protocols it
19 Multidisciplinary team Diabetologist Nephrologist Cardiologist Infectivologist Neurologist CLI Foot surgeon Orthopedic Plastic surgeon Podiatrist ENDO & OPEN revascularization Interventional radiologist Interventional cardiologist Vascular surgeon
20 Multidisciplinary team Diabetologist Nephrologist Cardiologist Infectivologist Neurologist CLI Foot surgeon Orthopedic Plastic surgeon Podiatrist ENDO & OPEN revascularization Interventional radiologist Interventional cardiologist Vascular surgeon
21 It doesn t matter what is the label of a physician, matters what he/she is able to do!
22 How to organize the multidisciplinary team work?
23 Protocols for infection treatment
24
25
26 Impossible to open PT neither antegradely nor retrogradely
27 Flow-guided surgery: what is the best forefoot amputation for this patient? Consider 3 key points Type Tissue Flow Biomechanical needs Distal TMA Proximal TMA ++ ++/ Trans-cuneiform Lisfranc Chopart
28 Proximal open TMA with accurate sparing of pedal-plantar loop vessel Bone coverage by Hyalomatrix application Skin graft
29 Multidisciplinary team means daily collaboration between vascular operators and foot operators.
30 To treat CLI we need a chain, however
31 The strength of a chain is the strength of the weakest ring, not the one of the strongest
32 Infection/ischaemia/amputation: how to build a multidisciplinary center for limb salvage Roberto Ferraresi Peripheral Interventional Unit Bergamo Italy ferraresi.md@gmail.com
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