Now That You Have the Tools

Transcription

1 Now That You Have the Tools Alan Jay Block, DPM, MS, FASPS, FACFAS Assistant Professor Dept Of Orthopeadics The Ohio State University Medical Board Kent State University Editor-in -Chief The Journal of the American Society of Podiatric Surgeons Past President The Ohio Foot & Ankle Medical Association

2 For some reason, it is considered conservative treatment to chop someone s leg off and aggressive treatment to even do an angiogram Craig M. Walker, M.D. Medical Director Cardiovascular Institute of the South

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5 GLOBAL WARNING 8.3% of the U.S population is diabetic 4.9% of the Population of India is Type 2 (61,300,000) 6.7% of the Population of China is Type 2 (90,000,000) 1 In 400 Children and adolescents in the USA is Diabetic and Obese

6 Amputations Less than 16% get an angiogram Only 36% get an ABI Most of these patients do have limb salvage options It is not conservative treatment to amputate!

7 DARWINS THEORY OF EVOLUTION???

8 Go Back we $#?/# up everything

9 You See What You Look for and You Recognize What You Know Lawerence Harkless, DPM

10 Which Patients are More Likely to Have Calcium? PAD Patients with Metabolic Disorders Leading to Calcified Plaque and Media Advanced Age Diabetics Kidney Disease 40.3M 65+yrs old in U.S. (1) 85+ age group is fastest growing in U.S. Up to 26M in U.S. (2) Diabetes is fastest growing health problem in U.S. (2) Up to 31M in U.S. (3) Diabetes is leading cause of kidney disease CSI U.S. Census Bureau, National Diabetes Fact Sheet Found on American Diabetes Association Website Searched on Dec. 26, American Kidney Fund Website: News Release Oct. 17, 2011

11 Patients % 5 YEAR MORTALITY RATES FOR PAD AND CLI Herlitz J, Hjalmarson A, Karlson BW, et al. 5-year mortality rate in patients with suspected acute myocardial infarction in relation to early diagnosis. Cardiology. 1988;75(4): Weitz JI, Byrne, J, Clagett GP, et al. Diagnosis and Treatment of Chronic Arterial Insufficiency of the Lower Extremities: A Critical Review Circulation.1996;94: ; Hartmann A, Rundek T, Mast H, et al. Mortality and causes of death after first ischemic stroke: the Northern Manhattan Stroke Study. Neurology. 2001;57: ; 7. Conrad MF, et al Journal of Vascular Surgery, 2011, 53(4): ]..

12 Angiography Routinely Underestimates Calcium 1 Angiography detects calcium in only 14% of arteries 1 Calcium? 1. J Endovasc Ther 2008;15: Angiography Underestimates PAD CSI-661 Yes!

13 Intervention in Unseen Calcium Can Result in Dissection 1 Calcium? Yes! 1. J Endovasc Ther 2008;15: Angiography Underestimates PAD CSI Images courtesy of Dr. Raymond Dattilo, MD, FACC, Director of Peripheral Interventions Kansas Heart and Vascular Center, Cardiology Consultants of Topeka, KS

14 Calcium Can Be Predicted Independent Calcium Prediction Variables 1. ABI > Critical Limb Ischemia 2 3. Diabetes: Especially if neuropathy present 3,4 4. Calcium found on forefoot X-Ray 4 5. History of tobacco use 2 6. Creatinine > Glomerular Filtration Rate (GFR) < Clev Clin Journ of Med 2006;73:s4. The magnitude of the problem of PAD: Epidemiology and Clinical Significance 2. J Am Coll Cardiol, 2008,51;20: Tibial Artery Calcification as a Marker of Amputation Risk in Patients with PAD. 3. Diabetologia 1993, Jul;36(7): Medial arterial calcification in the feet of diabetic patients. 4. Ann Vasc Surg 2008; 22:6. Arterial calcification increases in distal arteries. 5. J Am Soc Nephrol 2009, 20: Vascular Calcification: The killer of patients with Chronic Kidney Disease

15 You See What You Look for and You Recognize What You Know Lawerence Harkless, DPM

16 TREATING SOCIETY Dissemination of Information Technology Pathology Psychology

17 Only 31% of wounds heal 85% of amputations are preceded by a foot ulcer 80% of hospital admissions for diabetics are for infected foot ulcers Half the size in 4 weeks Vanderbilt Calcium Score Calcium=CLI= Amputation Paradigm Shift Restore the flow!!!

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27 Patient Background 83 yr old female Non-healing toe wound tissue loss, gangrenous Rest pain Smoker Left ABI 0.40 Stent in renal artery

28 Plaque Excision Procedure Pre Post Plaque excision using left SFA, popliteal, and TPT vessels Post SilverHawk TM procedure: Good flow through prior SFA occlusion, into popliteal and TPT SFA: Occluded 20% residual stenosis TPT: Occluded 25% residual stenosis

29 Time is Tissue Pre 60-days post Good distal flow to toes, resulting in healing of toe ulcer

30 Pre-Procedure Post-Procedure

31 Alan Jay Block, DPM, MS, FASPS, FACFAS Assistant Professor Dept Of Orthopeadics The Ohio State University Medical Board Kent State University Editor-in -Chief The Journal of the American Society of Podiatric Surgeons Past President The Ohio Foot & Ankle Medical Association

32 COMMINUTED PILON 49 Y.O. Train wreck 10 Months S/P Pilon FX Casted for 8 months KIDNEY/PANCREAS TRANSPLANT IMMUNOSUPPRESSIVE DRUGS DIABETIC/Peripheral Vascular Disease

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