Pre-operative management: risk assessment
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1 Pre-operative management: risk assessment Dr. B. Drieghe 21 st of April 2018 Moderators: Prof. Dr. S. Motte and Prof. Dr. P. Verhamme
2 VASCULAR ISSUES IN TYPE 2 DIABETES MURIEL SPRYNGER University Hospital Liège (Belgium) msprynger@chu.ulg.ac.be BENNY DRIEGHE University Hospital Gent (Belgium)
3 Macroangiopathy (arterial involvement) Coronary arteries Carotid arteries Lower limb arteries Microangiopathy (arteriolar and capillary involvement) Retinopathy Nephropathy Neuropathy Ulcers Medial calcification VASCULAR - INDEPENDENT RESEARCH AND EDUCATION EUROPEAN ORGANISATION
4 SPECIFIC FEATURES IN T2D Epidemiology 10-40% diabetic patients Earlier age More severe disease More diffuse and more distal : thigh + infra-popliteal lesions 45% limited to infra-popliteal arteries More progressive Bad collaterals Medial calcification : distal arteries Frequent sensory, motor and autonomic polyneuropathy Infection Neuropathic and ischemic ulcerations Amputation : 60% amputations in diabetic patients Frequently bilateral T2D + intermittent claudication = 20% amputations
5 MICROCIRCULATION : LOW CAPILLARY PERFUSION Increase of AV shunting : reduced O 2 delivery Increased affinity for O 2 of HbA1C (glycolized Hb) Disturbance of vasomotor activity : Dilated cutaneous vessels Warm foot Increased whole-blood and plasma viscosity Impaired ulcer healing VASCULAR - INDEPENDENT RESEARCH AND EDUCATION EUROPEAN ORGANISATION
6 MEDIAL CALCIFICATION Arterial stiffness : Interferes with BP measurement Impaired vessel compliance Diagnosis : X-rays US CT-scan Related to diabetes duration Usually linked to neuropathy : ulceration! Bad prognosis : All-cause deaths CV events Amputation
7 +LOWER LIMB ISCHEMIA
8 +DIABETES Intermittent claudication : Less typical Impaired sensitivity Late diagnosis : sometimes at critical ischemia stage! Distal lesions : no arterial bruit Distal sensitive neuropathy Autonomic neuropathy : «warm» foot Sedentarity Ageing (visual deficiency, arthrosis, dementia, social isolation ) Overweight Edema Infection Overestimated ABI (medial calcification) Wounds : unawareness or carelessness
9 DIABETIC FOOT Due to : «Ischemia» : 1/3 «Neuropathy» : 1/3 «Ischemia + Neuropathy» : 1/3 Rest pain, Loss of sensitivity Distal part of the foot Skin aspect : Dryness and scaliness Hairless toes Atypical calluses Breaks in the skin : frequently small and concealed under heavy callus!!! Chronic ulcers or gangrenous lesions Discoloration of the skin : Abnormal discoloration in the supine position Persistant cyanosis Pseudo-livedo reticularis (small embolic) Impaired nail growth (thickening) Foot deformities Neuropathy : Absence of vibratory sensation Filament test
10 +PERFORATING ULCER OF THE FOOT Neuropathy Painless Deep Hyperkeratosis Distal part of the sole
11 + FOOT WOUNDS ARE USUALLY (95%) CAUSED BY MINOR TRAUMAS Shoes (hallux valgus, hammer toe, foreign body ) Repeated strain while walking (perforating ulcer of foot) Inadequate pedicure : Badly cut or ingrown toenail Wound Mycosis Heat (hot water bottle, foot bath ) /cold + painless lesions, vision loss, overweight
12 PREDICTORS OF LOWER EXTREMITY (RE)AMPUTATION IN THE DIABETIC FOOT ACAR, KACIRA, J FOOT ANKLE SURG JUL 29 Adult males (OR 5.12) Longer term diabetes (OR 4.22) Wound infection (OR 3.94) Diabetic neuropathy (OR 3.53) History of smoking (OR 3.04) VASCULAR - INDEPENDENT RESEARCH AND EDUCATION EUROPEAN ORGANISATION
13 + ASYMPTOMATIC T2D PATIENT WHAT TO DO? MASKED ARTERIOPATHY? Sedentarity : heart failure, COPD, ageing Impaired sensitivity (T2D) More frequent in women Carelessness (6 walking test +) No? Yes? CV risk : diabetes = 10 y CV death 5-10% diabetes + PAD : 10 y CV death 10% Ulcer and amputation prevention!!!!
14 SYMPTOMATIC T2D PATIENT WHAT + TO DO? Intermittent claudication : Check up BMT (Supervised) training Training failure/iliac and/or CFA lesions : angioplasty-stenting? Surgery? Surveillance Critical limb ischemia Wound Infection Diabetic foot multidisciplinary team
15 +CHRONIC ISCHEMIA : CLINICAL EXAMINATION Skin/nail aspect Foot deformity Pulse examination Auscultation Position tests Edema due to rest pain : Sitting position during the night
16 +ABI = ANKLE BP/ARM BP (THE HIGHER) AHA 2011 Normal ABI : 1 < ABI < 1.4 ( : borderline) ABI < 0.9 : PAD (95% Sty-100% Spty) ABI 0.5 or ankle BP 50 (70-80) mm Hg : Severe PAD Multilevel disease Nonhealing ulcers, gangrene Ischemic rest pain ABI > 1.4 : Poorly compressible arteries Medial calcification : Overestimation of BP and ABI 1/3 diabetic patients Tips and tricks : Doppler waveform «Pole test» LASER Doppler : toe pressure TcPO 2
17 HYDROSTATIC PRESSURE MEASUREMENT : «POLE TEST» Approximate magnitude of the systolic ankle and foot pressure Supine position + foot elevation Determine the height (above the left atrium*, in cm) at which the systolic flow is no longer detected (Doppler) Conversion to BP : 13 cm blood column = 10 mm Hg BP * 18 cm VASCULAR - INDEPENDENT RESEARCH AND EDUCATION EUROPEAN ORGANISATION
18 probability of healing (%) PROBABILITY OF HEALING OF ISCHEMIC FOOT ULCERS ankle pressure toe pressure TcPO2 mmhg
19 +DUPLEX ULTRASOUNDS B Mode + Colour Doppler + PW Doppler Hemodynamics : Doppler waveform High velocity Distal pressure ABI Issues : Iliac arteries (?) Below-knee arteries Calcified plaques Echographist (?) Advantages : Harmless Highly available Cost
20 +CT-SCAN From aorta to feet with 1 injection Sty 90-95% and Spty 92-96% for >50% stenoses Calcifications : blooming Contrast agent Radiation
21 +MRI-MRA Contrast agent (gadolinium) Claustrophobia, pacemakers Calcifications Stents
22 +ANGIOGRAPHY Radiation Contrast agent : Hydratation Stop nephrotoxic drugs 48 h before Allergy Calcifications Distal vessels : «pseudo-occlusion» Invasive (+ angioplasty-stenting)
23 +MEDICAL TREATMENT CVRFs Glycemia! (neuropathy + microangiopathy) antiplatelets + statins + ACEI Vascular training Wound healing : Revascularisation? Infection Nursing Adapted shoes Local surgical treatment (abcess ) Chronic osteitis Treat infection before revascularisation to prevent uncontrolled infection Iloprost
24 +ANTIPLATELETS Aspirin : POPADAD : no evidence to support the use of aspirin in primary prevention of CV events and mortality in diabetic patients with asymptomatic PAD (ABI < 0.9) High prevalence of aspirin resistance in T2DM : High platelet turn-over Residual production of thromboxane Up-regulation of Aspirin-independent platelet paths Platelet over-reactivity due to atherosclerosis Proposals BID? 2 antiplatelets? Clopidogrel? Resistance to coated Aspirin in T2DM (Bhatt, JACC, 2017) Clopidogrel : CAPRIE : 3y superiority of Clopidogrel/aspirin in the PAD+T2DM group (deaths and MACE) EUCLID : symptomatic PAD, Ticagrelor = Clopidogrel COMPASS : Lancet 2017 Patients with a history of PAD of the lower extremities, of the carotid arteries, or stable CAD Rivaroxaban 2.5 mg BID + aspirin OD reduces major adverse cardiovascular and limb events when compared with aspirin alone.
25 +LOCAL TREATMENTS Nursing VAC Skin graft, plastic surgery Adapted pressure-relieving shoes Podology Custom-made footwear
26 +PROXIMAL REVASCULARISATION SFA stenting/fp graft (preferably saphenous vein) Indications : Disabling claudication persisting after a 3-month OMT Threatening proximal lesion (case to case discussion) : eg CFA thrombendarterectomy Non-healing ulcer Limb salvage CLI
27 +INFRA-POPLITEAL REVASCULARISATION Bypass/endovascular procedure Indications : Non-healing ulcer Limb salvage CLI The «angiosome concept» : anatomic unit of tissue (skin, subcutaneous tissue, fascia, muscle, and bone) fed by a source artery and drained by specific veins 3/foot Priority revascularisation of the corresponding artery Medial calcification!
28 +TAKE-HOME MESSAGES General CV risk : T2DM + IC = 50% 5y-deaths! Local risk : 5-25% T2DM patients will have 1 ulcer during their lifetime Increased risk of amputation (arteriopathy + neuropathy) 85% amputations are preceded by ulcer : prévention!!! Amputation : 17% in-hospital mortality Diabetic foot : Macroangiopathy + microangiopathy + medial calcification + neuropathy Multidisciplinary care Education : Patients and their close contacts Physicians and all caregivers
29 THANK YOU And don t forget Presentations will be available on the website :
30 Workshop overview PLENARY MEETING ROOM NL Peri-operative management of antithrombotic therapy Dr. Von Kemp How to approach asymptomatic carotid artery stenosis Dr. Drieghe How to treat patients with asymptomatic PAD Prof. Dr. De Backer EMERALD RUBY MEETING ROOM FR Peri-operative management of antithrombotic therapy Dr Borgoens / Prof Dr Motte How to approach asymptomatic carotid artery stenosis Dr Sprynger How to treat patients with asymptomatic PAD Prof Dr Wautrecht JADE SAPHIRE MEETING ROOM FR How to treat patients with asymptomatic PAD Prof Dr Wautrecht Peri-operative management of antithrombotic therapy Dr Borgoens / Prof Dr Motte How to approach asymptomatic carotid artery stenosis Dr Sprynger
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