Clinical Approach to CLI and Related Diagnostics: What You Need to Know

Transcription

1 Clinical Approach to CLI and Related Diagnostics: What You Need to Know Ido Weinberg, MD Assistant Professor of Medicine Harvard Medical School Massachusetts General Hospital

2 None Disclosures

3 Critical Limb Ischemia is the Most Severe Form of Peripheral Artery Disease

4 Many Patients Undergo Amputation Without Vascular Testing. Sad. Circ Cardiovasc Qual Outcomes Jan;7(1):142-50

5 Meet Mr. Bloch 61 years old PMHx: Mild well treated hypertension Hyperlipidemia Diabetes mellitus, diagnosed 2 years ago History of long-time tobacco abuse, quit 6 years ago Medications: Amlodipine 5 mg QD Simvastatin 20 mg QD Metformin 500 mg QD

6 Mr. Bloch can only walk 1 block What is his Rutherford class? Is this CLI? Ischemic rest pain, typically in the forefoot with confirmatory, objective hemodynamic studies (ABI <0.40, AP <50, TP <30, TcPO2 <20) Non-healing lower limb or foot ulceration of at least 2 weeks duration Gangrene involving any portion of the foot or lower limb What is your next diagnostic move? J Vasc Surg Jan;59(1): e1-2

7 Mr. Bloch s PVR s and Segmental Pressures Did you notice this is the wrong leg? Where is disease located? What is his prognosis?

8 PAD Natural History: Think Legs and Life Exertional Limb Discomfort In Men >Age 50 What Happens in the Next 5 Years? Limb Outcomes Life/Events Stable Sx Progression to Revasc CLI 70-80% 10-20% 1-2% Mortality 15-30% CV 75% Non-Fatal MI/CVA 10-20%

9 Would you Recommend Any Medication Changes for Mr. Bloch?

10 Medical Therapy for PAD: Summary Circ Res Apr 24;116(9):

11 5 Years Go By

12 Mr. Bloch is Seen by his PCP I injured my toe 3 weeks ago Is this CLI? What are your goals of care?

13 Mr. STEIN is Seen by his PCP I injured my toe 3 weeks ago Mr. Stein is: - 81 years old - Mild dementia, lives in a nursing home - Daily activities include sitting in a chair What are your goals of care?

14 Mr. LEVI is Seen by his PCP I got a cut on the bottom of my foot While walking on the beach last week Mr. Levi is: - 66 years old - Retired, active, lawyer - Republican speech writer This is Mr. Levi s foot today: What are your goals of care?

15 Goals of Care in Critical Limb Ischemia 1 Assess the patient Many patients do not achieve improvement J Vasc Surg Jun;51(6):

16 Goals of Care in CLI Cont d 1 Assess the patient Functional Status Wound Characteristics Eur J Vasc Endovasc Surg May;43(5):540-7

17 Goals of Care in CLI Cont d 1 Assess the patient

18 Goals of Care in CLI Cont d 2 Assess the wound J Vasc Surg Jan;59(1): e1-2

19 ABI/TBI: Bedside Prognosis DM? Think TBI Diabetic microangiopathy should not be considered to be the cause of poor wound healing in patients with a foot ulcer. (Strong; Low) In patients with a non-healing ulcer with either an ankle pressure <50mmHg or ABI <0.5 consider urgent vascular imaging and revascularisation. (Strong; Moderate) J Vasc Surg Jan;59(1): e1-2

20 TcPO2: Bedside Prognosis DM? Think TcPO2 Any of the following findings increases the pre-test probability of healing by at least 25%: a skin perfusion pressure 40mmHg; a toe pressure 30mmHg; or, a TcPO2 25 mmhg. (Strong; Moderate) Consider urgent vascular imaging and revascularisation in patients with a foot ulcer in diabetes where the toe pressure is <30mmHg or the TcPO2 <25 mmhg. (Strong; Low) J Vasc Surg Jan;59(1): e1-2

21 Is Imaging Necessary for Mr. Bloch Yes: Before a Procedure? Helps plan the procedure (e.g. target vessel/lesion) Ensures endo-first approach feasible No: Angiogram will be done anyway Avoid complications (i.e. renal failure)

22 Which Imaging Modality is Useful in Mr. Bloch s Case? Duplex ultrasonography: Pros: Cheap Reproducible No radiation, no dye Cons: Poor value for aorta and proximal iliac arteries Poor value for below the knee anatomy, especially posterior circulation Multi-level disease can be hard to assess (downstream effect of proximal stenosis)

23 This is Mr. Bloch s DUS: Is there another lesion?

24 This is Mr. Bloch s CTA Apparently, he only had proximal disease after all

25 TcPO2 may be Used to Choose a Target Vessel / Lesion The aim of revascularisation is to restore direct flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the wound, with the aim of achieving a minimum skin perfusion pressure 40mmHg; a toe pressure 30mmHg; or, a TcPO2 25 mmhg (Strong; Low) J Vasc Surg Apr;7(4):

26 Angiosomes to Choose a Target Vessel / Lesion

27 Mr. Bloch s Toe is Healing Nicely. What is the Best Way to Image in Follow-up? J Am Coll Cardiol Jul 17;60(3):242-76

28 @Angiologist