Clinical targets and patient outcome goals in BTK intervention
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1 Clinical targets and patient outcome goals in BTK intervention Roberto Ferraresi Peripheral Interventional Unit Bergamo Italy
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 Clinical targets and patient outcome goals in BTK intervention 1. Limb salvage 2. Wound healing 1. A functional limb through limb salvage or leg amputation 2. Biomechanics & flow-guided foot surgery 3. Patient centered approach
4 Restenosis after POBA in BTA vessel Basal Angio 1 PTA 2 PTA 3 PTA 4 PTA 5 PTA
5 1 PTA 3/08/ PTA + 5 months 3 PTA + 5 months 26 months of recurrent pain, inability to walk, infections, dressings, hospitalizations, multiple minor amputations This is what we call limb salvage! 4 PTA + 4 months 5 PTA + 5 months 6 PTA + 6 months
6 Limb salvage alone cannot be considered a goal in BTK-CLI treatment: we must save something useful for walking! Fighting for an impossible mission in BTK-CLI can lead to months of: Inability to walk Chronic wound Need for daily dressing Repeated infections Repeated hospitalization Personal & family desperation
7 Clinical targets and patient outcome goals in BTK intervention 1. Limb salvage 2. Wound healing 1. A functional limb through limb salvage or leg amputation 2. Biomechanics & flow-guided foot surgery 3. Patient centered approach
8
9 Wound healing and timeto-healing are wonderful targets in the physician s mind, however we must save something useful for walking!
10 Clinical targets and patient outcome goals in BTK intervention 1. Limb salvage 2. Wound healing 1. A functional limb through limb salvage or leg amputation 2. Biomechanics & flow-guided foot surgery 3. Patient centered approach
11 Patient s goal is maintaining independence; the key is maintaining ambulation via limb salvage or prosthesis Think biomechanics! Prof Chris Attinger VSS, JVS 10:108, 1995 Buzato MA, åcta Chir Belg 102:248, 2002
12 Active pts demand function Patients with good neuromuscular capacity can have an active life wearing a modern prosthesis
13 Fragile pts demand independence After BKA, ambulation rate 16% to 78% Risk of not wearing prosthesis 10x: Non-ambulatory pre-op 4.4x: AKA 2.7x: > 60 yy 3x: 2x: homebound CAD Taylor S, JVS 42:227, 2005 Courtesy Prof Chris Attinger
14 Fragile pts demand independence
15 Ambulation via limb salvage or amputation is the ONLY goal Salvage or amputation should be viewed as giving the pt a new leg and should be done with equal attention to detail Think biomechanics! Courtesy Prof Chris Attinger
16 Clinical targets and patient outcome goals in BTK intervention 1. Limb salvage 2. Wound healing 1. A functional limb through limb salvage or leg amputation 2. Biomechanics & flow-guided foot surgery 3. Patient centered approach
17 The functional foot Reconstruction must optimize function in residual leg or foot Reconstruction goal is a functional foot that redistributes weight to avoid high pressure points on the plantar foot Most diabetics are insensate and cannot recognize high pressure points Failure to make this the primary concern will lead to sub-optimal or no-function Courtesy Prof Chris Attinger
18 Use every tool at your disposal: Control infection Prepare wound bed Optimize blood flow Think biomechanics! Courtesy Prof Chris Attinger
19 Type Tissue Flow Biomechanical needs Distal TMA Proximal TMA ++ ++/ Trans-cuneiform Lisfranc Chopart
20 Proximal open TMA with accurate sparing of pedal-plantar loop vessel Bone coverage by connective tissue substitute Skin graft
21 NO-SAD SAD Small Artery Disease (SAD)
22 Tension-free surgery avoid any tension that could precipitate local necrosis: dermal substitute, VAC etc.
23 Foot surgery must be always tailored on biomechanics & blood supply
24 Clinical targets and patient outcome goals in BTK intervention 1. Limb salvage 2. Wound healing 1. A functional limb through limb salvage or leg amputation 2. Biomechanics & flow-guided foot surgery 3. Patient centered approach
25 TASC II Critical limb ischemia is a bag in which we put every patient with PAD and foot suffering
26 Causes of PAD Foot lesion CLI Patient status Obstruction pattern
27 TASC II The prevalence of CAD and cerebral artery disease in PAD pts is 40-60%. In our CLI pts >70% have a history of CAD and >30% cerebrovascular disease DOPPS Study The prevalence of CLI in ESRD-HD pts ranges between 4-17% In our CLI pts: 30% are ESRD-HD 16% have >2.0 mg/dl serum creatinine
28 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 maximize a patient-centered outcomes.
29 CLI is a complex disorder We can treat it only pursuing a patient-centric approach in a multidisciplinary team
30 Clinical targets and patient outcome goals in BTK intervention Roberto Ferraresi Peripheral Interventional Unit Bergamo Italy
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