Multidisciplinary approach to BTK Y. Gouëffic, MD, PhD
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1 Multidisciplinary approach to BTK Y. Gouëffic, MD, PhD Department of vascular surgery, University Hospital of Nantes, France
2 Response to the increased demand of hospital care Population is aging Diabetes - Renal insufficiency During the preceding decade the number of individuals with PAD, increased by 28 7% in LMIC and 13 1% in HIC. Fowkes, Lancet, 2013
3 CLI: a high risk population Age - Diabetes - Renal insufficiency High morbidity outcomes after open revascularization Baumgartner, Eur J Vasc Endovasc Surg, 2006 Wasmuth, Eur J Vasc Endovasc Surg, 2009 Norgren, Eur J Vasc Endovasc Surg, 2007
4 Diabetic foot Foot ulcer: 25% of patients with diabetes Precede more than 8 in 10 non-traumatic amputations Pathophysiologic mechanisms: Neuropathy, infection, ischemia, abnormal foot structure, biomechanics Complex clinical problem => requiring a multidisciplinary approach Sumpio, J Vasc, Surg, 2010
5 Significant deficit in the adherence to published guidelines for atherosclerosis risk-factor management - Less than one-third of patients with CLI present with their risk factors optimally managed - Patients who are medically undertreated have an eight-fold risk of major amputation and/or death The magnitude of the effect suggests that future trials and quality assessments should stratify outcomes by the quality of baseline medical management Hogh, Eur J Vasc Endovasc Surg, Chung, J vasc, 2013
6 Suboptimal outcomes after revascularization Despite novel techniques and therapies devices: - 25% of patients fail to survive with an intact limb at 1 year (Conte, J Vasc Surg, 2009) There is room for improvement to improve: - Survival - Amputation free survival - Patency - Primary patency about 34% and amputation free survival up to 75%. (Conrad, J Vasc Surg, 2011) - Wound-healing outcomes vary widely in the literature, with complete wound healing - Wound achieved healing in 40% to 50% of patients between 6 and 10 months.(chung, J Vasc Surg, 2006; Fernandez, J Vasc Surg, 2010)
7 Failed trials Multi center Randomized Trial 358 patients R3 to 6 Avg lesion length 100 to 120-mm Iy endpoints: LLL and TLR Failure Hypothesis? IN.PACT Amphirion vs. PTA in patients with CLI and infrapopliteal revascularization IMPACT DEEP 12-onth Results: - Selection of patients: what are LLL: NS the / TLR: best NS candidates? - Lack of medical FU?
8 In CLI patients: - comorbidity is higher - medical treatment is still suboptimal - Outcomes of open and endovascular repair should be optimized by medical follow up (drugs, wound care ) => CLI patients requires a MultiDisciplinary Care (MDC)
9 MultiDisciplinary Care (MDC) Vital core: Vascular interventionalists (surgeons, cardiologists, radiologists ) Podiatric surgeon More extensive team: Plastic, orthopedic, and general surgery Cardiology, diabetes and infectious specialists Unfortunately, comparative-effectiveness research to date is insufficient to define the optimal multidisciplinary team. Chung, J Vasc Surg, 2015
10 Vascular interventionalists To improve blood flow wound care wound healing limb salvage Revascularization remains the single most significant factor independently predicting major amputation or death, or both, in CLI by greater than a factor of three. Chung, J Vasc Surg, 2015
11 Podiatric surgeons - They use techiques that are outside of the scope of most general and vascular surgeons, which may also contribute to improved outcomes - Off-loading strategies such as total contact casting and removable walkers, which resulted in significant accelerations in healing times..
12 Amputation free-survival (AFS) Chung, J Vasc Surg, Retrospective single-center cohort of consecutive CLI patients - SWC: inconsistent mix of providers without a defined manager - MDC: vascular, plastic, and podiatric surgeons who jointly managed wound care and directed any other consults or services as deemed necessary. - The referring physician determined the allocation of patients. 146 CLI patients Median FU: 539 d Ischemic tissue loss: 58% (R5, R6) SWC: 40% - MDC: 60% 68% underwent a revascularization 8%: primary major amputation independent - MultiDisciplinary predictors Care versus Standard of major amputation or death, or both: Wound Care - No revascularization Durable two fold increase in AFS - Initial nonambulatory status
13 (Based on an analysis of the cost of a limb salvage team review -) - Implementation of the MDC to manage diabetic foot ulcers within a given region or health care system has been reported to reduce longterm amputation rates from 82% to 62%. - The MDC approach gradually leads to improved screening and prevention programs and earlier interventions, and thus seems to reduce long-term costs.
14 Nantes university hospital (France) Patient with diabetes and CLI 1 meeting a week - Podiatric surgeon - Vascular surgeon - Diabetologist - Vascular physician - Infectious disease specialist - Nurse
15 Clinical examination ABI - Duplex scan - TcPO2 Blood samples To identify the disorders CLI, hyperglycemia, local infection, neuropathic foot To define treatment strategy Medical treatment - Revascularisation - Debridement Off loading Dressings - Negative-pressure wound therapy
16 M. JER. 55 years-old Cardiovascular risk factors: - active smoking (100 packs/year) - diabetes metillus type 2 Medical history: coronary artery disease Refer for a non healing ulceration of the right foot since 1 month - ABI: Duplex scan: no significant stenoses of the femoropliteal segment - TcPO2: normal - X-Ray: osteomyelitis
17 Management Neuropathic ulceration Medical treatment: optmization of diabetes treatment Antiplatelet treatment Revascularisation: / Debridement: ambulatory hospitalization for minor amputation and tissue harvesting to figure out the antibiotherapy Off loading: shoes
18 M. DUJ. 72 years-old Cardiovascular risk factors: - diabetes metillus type 2 - Hypercholesterolemia Medical history: psoriasis Refer for a fever and non healing ulceration of the right foot since 2 weeks - ABI: Duplex scan: no significant stenoses of the femoropliteal segment - TcPO2: non contributive - X-Ray: osteomyelitis
19 Management Neuropathic ulceration and septicemia Hospitalization Debridement: minor amputation and tissue harvesting to figure out the antibiotherapy Medical treatment: optmization of diabetes treament Antiplatelet treatment Revascularisation: should be discussed in case of delayed wound healing Off loading: shoes
20 M. PET. 69 years-old Cardiovascular risk factors: - Active smoking (60 packs/year) - Diabetes metillus type 2 - Hypercholesterolemia Refer for rest pain and non healing ulceration of booth limbs since 1 month Medical history: - coronary artery disease - Claudication (left limb) ABI: 0.5/0,5 Duplex scan: femoropopliteal thromboses TcPO2: / X-Ray: normal
21 Management Ischemic ulceration (R5) Hospitalization Revascularization Dressing Medical treatment: - optmization of diabetes treament - antiplatelet treatment statins - antibiotherapy after harvesting
22 CLI Revascularisation Endovascular as a first line of treatment Arteriography antegrade operating room diagnosis treatment
23 Take home messages MDC improves access to care, because multiple team members can see the patients. MDC improves the potentially to intervene before the development of irrevocable necrosis in the foot. MDC improves operative selection: room for improvement MDC improves the ability to survey and post- amputation wound care
24 Multidisciplinary approach to BTK Y. Gouëffic, MD, PhD Department of vascular surgery, University Hospital of Nantes, France
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